Payment Integrity Analyst II - Data Mining

TBC Corporation

About The Position

Lyric is an AI-first, platform-based healthcare technology company focused on simplifying healthcare by preventing inaccurate payments and reducing waste, thereby lowering the cost of care for all stakeholders. Recognized as a market leader with 35 years of pre-pay editing expertise, Lyric is committed to innovation with AI. The Payment Integrity Analyst II (Data Mining) supports the Data Mining (DM) program by independently investigating moderate-to-complex payment errors stemming from incorrect processing of payment policies, contract terms, billing, and/or coding. This role aims to prevent and recover improper claim payments through hands-on casework, including investigation, documentation, and system updates. The analyst applies advanced analytical skills to interpret claims and reimbursement data, identify trends and false positives, and contribute to concept development and process improvements within the DM program. Operating with increased autonomy, the analyst resolves non-routine scenarios, improves workflows, logic, and data quality, and collaborates cross-functionally to achieve scalable payment integrity outcomes.

Requirements

Minimum of five (5) 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 three (3) years of experience auditing medical claims or performing payment integrity casework, including independent handling of moderately complex scenarios.
Minimum of three (3) years of experience performing data analysis with large datasets.
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

Nice To Haves

Bachelors degree in business or healthcare/related field
Demonstrated ability to analyze and interpret payment policies, contract terms, and reimbursement methodologies across professional and facility claims.
Excellent verbal and written communication skills
Excellent documentation accuracy and attention to detail
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
Experience supporting audit concept development, validation, or rule refinement within a data mining or payment integrity program.
Demonstrated experience contributing to process improvement initiatives with measurable impact on accuracy, turnaround time, or false positives.
Familiarity with contract terms, payment policies, and root cause analysis for payment errors.
Working knowledge of claim adjudication workflows and payment rules.
Experience building queries/filters or using reporting tools; basic SQL or query-tool proficiency preferred.
Experience in high-volume, SLA-driven operations environments.
Ability to identify trends and translate findings into actionable operational or analytical improvements.
Creative thinker with an entrepreneurial spirit

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.
Deliver validated DM outcomes that support downstream payment integrity activities (recovery, reprocessing, adjustments) with minimal rework.
Consistently meet or exceed established productivity, turnaround time, and quality standards while managing a varied and moderately complex workload.
Demonstrate increasing independence in managing inventory, prioritizing work, and resolving issues with limited oversight.
Identify and escalate operational risks, inconsistencies, or process gaps that may impact performance or outcomes.
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.
Recommend process improvements and data enhancements that improve accuracy, reduce rework, and support more effective audit outcomes.
Use advanced Excel and other tools to support ad hoc analysis (e.g., trend review, inventory quality checks, and performance insights).
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.
Contribute to refining audit concepts, validation approaches, and workflow improvements based on observed trends and findings.