Lyric - Clarity in motion. · 1 day ago
Sr. Payment Integrity Specialist - Data Mining
United States
Full-time
Remote
Senior Level, Lead/Staff
$85K/yr - $128K/yr
8+ years expLyric is an AI-first, platform-based healthcare technology company, committed to simplifying the business of care. The Sr. Payment Integrity Specialist (Data Mining) leads investigations to validate correct reimbursement and prevent improper claim payments, applying advanced analytical skills in a high-volume environment.
ConsultingPaymentsHealthcareSoftwareInformation TechnologyBillingConsumer SoftwareHealth CareTransaction Processing
No H1B
Responsibilities
Review, prioritize, and independently work assigned DM leads (automated and manual), including moderate-to-complex and high-dollar cases, to determine verification steps and next actions
Investigate and validate payment terms (Inpatient, Outpatient, Professional, Ancillary) using internal systems, payer portals, contracts, and other approved data sources
Apply payment policies, contract terms and coding guidelines, including CMS and AMA guidance as applicable, to determine the correct reimbursement and document the rationale for the payment determination
Reconcile discrepancies across sources (contract data and paper forms, conflicting policy and contract terms) and drive cases to a clear, audit-ready determination; escalate edge cases per policy
Analyze claim inventory from identification to resolution. Develop concept overviews and analysis. Collaborate with team to configure client specific business rules
Compile sample claims and supporting documentation for Client review and approval. Maintain a library that includes instructions for validating specific audit concepts
Create clear, detailed, and accurate case notes that capture verification steps, evidence, and outcomes in internal tools to support audits and downstream recovery/reprocessing
Prepare and evaluate documentation needed for inquiries, client/provider disputes, and appeals related to determinations, as assigned
Perform quality checks on your work and as assigned, peer outputs prior to submission/export to ensure accuracy, completeness, and compliance with internal standards and regulatory expectations
Serve as a DM SME: provide knowledge share, mentoring, and coaching to Specialists; support new hire onboarding and training as needed
Support inventory management by helping to isolate and distribute work and by proactively flagging capacity, risk, and prioritization needs to leadership
Meet or exceed established productivity, turnaround time, and quality/audit standards while managing a high-volume case queue with a high degree of autonomy
Identify and solve problems by surfacing errors and overpayments, documenting root causes, and recommending corrective actions that reduce rework and improve yields
Track outcomes and error categories, identify drivers of recurring issues and false positives, and recommend opportunities to streamline research, improve data quality, and enhance logic
Use advanced Excel and other tools to support ad hoc analysis (e.g., trend review, inventory quality checks, and performance insights); develop simple trackers or reporting views to support operational decisions
Demonstrate strong understanding of query and filter construction (and/or similar investigative tooling) to identify opportunities; partner with stakeholders to test and implement workflow or tool enhancements and measure impact
Qualification
Required
Minimum of eight (8) years of combined experience in healthcare, such as prior work in health insurance, claims processing or adjudication, overpayment, fraud, and/or waste and abuse detection
Minimum of eight (8) years experience auditing medical claims to identify improper payments as a Payment Integrity Vendor or within a Health Plan's Payment Integrity team
Advanced proficiency with Excel and comfort working with large data sets and multiple systems/portals; ability to produce clear summaries and operational insights
Working knowledge of medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, and NDC, as well as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS
Demonstrated ability to analyze and interpret payment policies and payment methodologies for Commercial, Managed Care, Medicare, and Medicaid with direct experience in various claim payment methodologies for professional, facility, and ancillary providers
Excellent verbal and written communication skills
Excellent documentation accuracy and attention to detail; ability to maintain an audit-ready work product
Ability to work within established productivity and quality metrics while prioritizing workload with minimal supervision
Strong problem-solving skills with the ability to resolve conflicting or incomplete information and escalate appropriately
Ability to maintain confidentiality and comply with HIPAA and data security standards
Preferred
Bachelors degree in business or healthcare/related field
Experience performing quality review/quality control and providing feedback or coaching to improve team outcomes
Demonstrated process improvement experience (e.g., SOP development, workflow redesign, training updates) with measurable impact on accuracy, turnaround time, or false positives
Familiarity with contract terms, payment policies, root cause analysis for payment errors used on data mining projects
Working knowledge of claim adjudication workflows and payment rules
Experience building queries/filters or using reporting tools to identify opportunities; basic SQL or query-tool proficiency is a plus
Experience in high-volume, SLA-driven operations teams; comfort operating in a metric-driven environment
Creative thinker with an entrepreneurial spirit
Company
Lyric - Clarity in motion.
Lyric is the payment integrity Al company trusted by the nation's leading health plans at the beginning of the claims payment workflow.
501-1000 employees
Funding
Current Stage
Late StageTotal Funding
$90.9M2023-08-18Undisclosed· $90.9M
2022-04-25Acquired
Leadership Team
Halsey Wise
Member Board of Directors
Meera Atkins
Chief Medical Officer
Recent News
2025-08-07
2025-08-06
2025-08-06
Company data provided by crunchbase