Sr. Payment Integrity Specialist - Data Mining

TBC Corporation

About The Position

Lyric is an AI-first, platform-based healthcare technology company, committed to simplifying the business of care by preventing inaccurate payments and reducing overall waste in the healthcare ecosystem, enabling more efficient use of resources to reduce the cost of care for payers, providers, and patients. Lyric, formerly ClaimsXten, is a market leader with 35 years of pre-pay editing expertise, dedicated teams, and top technology. Lyric is proud to be recognized as 2025 Best in KLAS for Pre-Payment Accuracy and Integrity and is HI-TRUST and SOC2 certified, and a recipient of the 2025 CandE Award for Candidate Experience. Interested in shaping the future of healthcare with AI? Explore opportunities at lyric.ai/careers and drive innovation with #YouToThePowerOfAI. Applicants must already be legally authorized to work in the U.S. Visa sponsorship/sponsorship assumption and other immigration support are not available for this position. The Sr. Payment Integrity Specialist (Data Mining) serves as a subject matter expert within the Data Mining (DM) program, leading moderate-to-complex investigations to validate correct reimbursement based on medical and payment policy and provider contract terms to reconcile, prevent and recover improper claim payments. This role performs hands-on casework in a high-volume environment including outreach, documentation, and system updates, while applying advanced analytical skills to interpret claims and eligibility data, identify trends and false positives, and drive process and reporting improvements that improve accuracy and outcomes for the DM program.

Requirements

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.

Nice To Haves

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

Responsibilities

Investigation and verification 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.
Collaboration, documentation, and system updates 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.
Quality, SME support, and operational ownership 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.
Process improvement and analytical contribution 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.