SmartLight Analytics · 15 hours ago
Lead Pharmacy Payment Integrity Analyst
United States
Full-time
Remote
Mid, Senior Level
4+ years expSmartLight Analytics is a company focused on reducing the rising cost of healthcare through data analysis. The Lead Pharmacy Payment Integrity Analyst plays a crucial role in analyzing healthcare data to improve patient outcomes and optimize clinical workflows, ensuring accurate claims processing and preventing overpayments.
AnalyticsHealth CareInformation TechnologySoftware
No H1B
Responsibilities
Identify and investigate healthcare billing activities leading to improper payments. This work involves reviewing medical professionals, facilities, 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, medical reviews, 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, claims adjudication, clinical auditing, payment integrity operations and/or healthcare reimbursement
Strong knowledge of clinical terminology, medical procedures, 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
Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomes
Problem-Solving: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutions
Attention to Detail: High level of precision and accuracy in handling critical data
Preferred
CPC, CCS or other relevant clinical/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 or experience in a healthcare provider's practice
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