Pharmacy Payment Integrity Analyst

SmartLight Analytics • Plano, TX

5d

About The Position

The Pharmacy Payment Integrity Analyst plays a critical role in analyzing and interpreting healthcare data to provide actionable insights for improving patient outcomes, optimizing clinical workflows, and supporting healthcare decision-making. This position ensures accurate claims processing, policy interpretation, and regulatory alignment to prevent overpayments and cost-effective healthcare payments. This is NOT a Data Analyst Position with SQL and data sets. This position is only eligible for legal residents of the United States of America.

Requirements

• 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

Nice To Haves

• 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

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1-10 employees