Job Title: Clinical Claims Review Analyst Department: Patients Accounts Reports to: Claims Appeal Team Lead Date **** Overall Purpose of the Role The mission of the Beacon Hospital is to provide exceptional patient care in an environment where quality, respect, caring and compassion are at the core of our practice.
This commitment extends to the governance of clinical documentation, insure engagement, and the financial sustainability of the organisation.
The Clinical Claims Review Analyst provides clinical oversight and expertise in the review of aged, part-paid, and disputed insurance claims.
The role focuses on determining the clinical defensibility of claims, supporting the preparation of appeal correspondence to insurers,and advising Senior Hospital Management, including the CFO, on the appropriateness of internal reconciliation.
This role is responsible for the end-to-end life-cycle of claim review, data management, insurer/internal communications and resolution.
This role acts as a key clinical interface between Patient Accounts, Insurers, Consultants, and Hospital leadership, ensuring that reimbursement decisions are clinically sound, contractually appropriate, and well-governed.
Successful candidates will report directly to the Claims Appeal Team Lead with a secondary reporting line to the Head of Surgical Services for clinical governance.
Key Responsibilities and Deliverables Claims Appeal Team - Review, Appeals, Clinical Feedback Clinically review aged and part-paid insurance claims to assess the appropriateness of insurer payment decisions.
Determine whether claims are clinically appealable, based on medical necessity, documentation completeness, and insurer policy rules.
Provide clinical input and justification to support formal appeal letters to insurers, including articulation of medical necessity and treatment rationale.
Assist in the preparation of written recommendations to Hospital Senior Management regarding claim balances.
Review and interpret clinical records, operative reports, discharge summaries, and consultant notes to support claims and appeals.
Work collaboratively with consultants and clinical departments to clarify care pathways, coding rationale, and documentation.
Support the Insurance Collections Analysts Claims Appeal Team, by providing clinical interpretation and guidance on complex claims and insurer queries.
Identify recurring themes in claim disputes or part payments and provide feedback to clinical and finance teams to improve future claim quality.
Ensure all clinical claim reviews and recommendations are clearly documented, auditable, and aligned with hospital policies.
Maintain strict confidentiality and compliance with data protection, clinical governance, and hospital guidelines.
Contribute to departmental meetings, service reviews, and continuous improvement initiatives relating to claims and insurer engagement.
Insurance Audits Compliance Participate in internal and external health insurance audits Prepare clinical and billing documentation required for audits Respond to insurer audit queries in a timely and accurate manner Support compliance with healthcare regulations, payer contracts, and billing standards Identify audit risks and recommend process improvements Collaboration Reporting Work closely with clinicians, finance, and administrative teams Maintain accurate records and audit trails Generate reports on claim status, disputes, and audit outcome The timely identification and communication of any issues to the Manager.
Demonstrate a confidence and competence in hospital policies and guidelines.
Efficient recording of all necessary documentation.
Effective management of complaints.
Maintaining an effective interdisciplinary communication process.
Personal Professional Responsibilities The post holder is expected to: Maintain a professional portfolio and keep their professional registration up to date.
Attend appropriate study days and courses.
Participate in their performance review with their manager.
Educational Responsibilities Under the direction of the Managers the post holder will: Identify and contribute to the continual enhancement of learning opportunities in their area.
Assume responsibility for own learning and development needs.
Other Duties and Responsibilities Utilise effective time management skills.
All employees are expected to remain flexible to meet the needs of the Hospital Maintain strict confidentiality and compliance with data protection, clinical governance, and hospital guidelines.
Contribute to departmental meetings, service reviews, and continuous improvement initiatives relating to claims and insurer engagement.
Person Specification Registered healthcare professional (e.g. Nurse, Allied Health Professional, or equivalent clinical background).
Relevant clinical qualification essential.
Additional qualifications or experience in health administration, utilisation review, or insurance-related roles desirable.
Qualifications Clinical background (e.g., Nursing, Allied Health, or similar healthcare qualification) Experience Significant post-qualification clinical experience in an acute hospital setting.
Experience reviewing clinical records and assessing medical necessity or appropriateness of care.
Previous involvement with insurance claims, audits, utilisation review, or appeals is highly advantageous.
Job Specific Competencies and Knowledge Teamwork Demonstrate ability to work as part of a multi-disciplinary team.
Demonstrate motivation and an innovative approach to the role and tasks.
Communication Interpersonal Skills Demonstrate effective communication skills including the ability to present information in a clear and concise manner.
Demonstrate an understanding of change management.
Strong ability to interpret and summarise complex clinical information for nonclinical stakeholders.
Sound understanding of how clinical decision-making impacts insurance reimbursement and claim outcomes.
Excellent written communication skills, particularly in drafting or contributing to formal appeal and governance correspondence.
Ability to exercise professional judgement when determining claim outcome recommendations.
Confident communicator with clinicians, finance teams, insurers, and senior management.
High attention to detail with a structured, evidence-based approach to claim review.
Experience using Microsoft Excel and other Microsoft Office applications (e.g.Word, Outlook, Power BI) is beneficial for tracking, reviewing, and supporting claim activity.
Strong awareness of confidentiality, discretion, and clinical governance requirements.
Planning Organising Demonstrate evidence of effective planning, organising and time management skills.
Demonstrate flexible approach Knowledge Experience of medical billing and insurance claims Understanding of clinical documentation and its impact on billing Familiarity with health insurance processes and audits Strong attention to detail and analytical skills Excellent written and verbal communication skills Patient Customer Focus Demonstrate a focus on quality.
Demonstrate evidence of ability to empathise with and treat patients, relatives and colleagues with dignity and respect.
Personal Competencies Highly organised with the ability to manage complex reviews across multiple claims.
Comfortable working autonomously while contributing to a multidisciplinary team.
Objective, balanced, and outcomes-focused in decision-making.
Able to prioritise work in a deadline-driven environment.
Fluent written and spoken English.
All posts in Beacon Hospital require a high level of flexibility to ensure the delivery of an effective and efficient service.
Therefore, the post holder will be required todemonstrate flexibility as and when required by their manager or hospital management.
This job description is intended to be an outline of the areas of responsibility and deliverables at the time of its writing.
As the Hospital and the post holder develop, this job description may be subject to review in light of the changing needs of the Hospital.