SmartLight Analytics · 1 week ago
Lead Pharmacy Payment Integrity Analyst
United States
Full-time
Remote
Senior Level, Lead/Staff
4+ years expSmartLight Analytics is a company focused on reducing healthcare costs through data analysis. The Pharmacy Payment Integrity Analyst plays a critical role in analyzing Pharmacy data to provide insights for improving patient outcomes and ensuring accurate claims processing.
AnalyticsHealth CareInformation TechnologySoftware
Responsibilities
Identify Pharmacy billing activities leading to improper payments. This work involves reviewing Pharmacy claims, insured members, or the broker community in coordination with the customer’s carrier or third-party administrator
Review claims data and conduct analysis to look for patterns of potential improper payments
Utilizing information from claims data analysis, plan members, and other sources to conduct confidential claims data reviews, relevant investigative activities, document actionable findings and report any suspect billing that could result in an overpayment through designated channels
Conduct data analysis to review claim and case history
Reviews claims history, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State sites, etc
Identify and resolve issues related to data discrepancies, missing data, or inconsistencies within clinical datasets
Qualification
Required
Bachelor's degree or 4 – 6 years of equivalent work experience in healthcare administration, billing, Pharmacy claims adjudication, Pharmacy auditing, payment integrity operations and/or healthcare reimbursement
Strong knowledge of clinical terminology, medical procedures, Pharmacy and healthcare workflows
Ability to be concise, independent and provide defensible decisions in writing
Detail-oriented with excellent communication skills (oral presentations and written) and interpersonal skills
Strong critical-thinking, communication and attention to detail skills
Preferred
CPhT, CPC, CCS or other relevant clinical/Pharmacy/coding certifications strongly preferred
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (commercial health plans and/or dental plans)
3+ years of experience working in the group health business with pharmacy as an emphasis
Experience in the healthcare industry, clinical research or working clinical trials
Company
SmartLight Analytics
SmartLight Analytics reduces health care costs for self-funded employers with analytics and results-oriented solutions.
2-10 employees
Funding
Current Stage
Early StageLeadership Team
Asha George
CEO and Co-Founder
Franklin E Baumann, MD
Chief Medical Officer and Co-Founder
Company data provided by crunchbase