Lead Pharmacy Payment Integrity Analyst
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Job Location:
Monthly Salary:
Posted on:
29 days ago
Vacancies:
1 Vacancy
Job Summary
Position Overview:
ThePharmacyPayment IntegrityAnalystplays a critical role in analyzing and interpretingPharmacydatatoprovideactionable insights for improving patient outcomesoptimizingclinical workflows and supporting healthcare processing policy interpretation and regulatory alignment to prevent overpayments and cost-effective healthcare payments.
Whatyoulldrive:
Youllidentify wasteand inaccuratePharmacyclaims
Youllwork withindustry leadingAI predictive analytics and automation platforms to uncover patterns and drive smarter decisions.
Youllfoster a culture of learning refinement and ethical excellenceto create high qualityevidence-backedreferrals that reduce health insurance costs.
Whatyoulldo:
IdentifyPharmacybillingactivities leading to improper payments. This work involves reviewingPharmacyclaimsinsured members or the broker community in coordination with the customers 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 historyprovider analysis techniques to detect irregularities billing trends and financial relationships using state boards licensing sites Secretary of State sitesetc.
Identifyand resolve issues related to data discrepancies missing data or inconsistencies within clinical datasets
What you bring:
Bachelors degreeor46years ofequivalent work experienceinhealthcare administration billingPharmacyclaims adjudicationPharmacyauditingpayment integrityoperationsand/or healthcare reimbursement
CPhTCPC CCS or other relevant clinical/Pharmacy/coding certificationsstronglypreferred.
Strongknowledge of clinical terminology medical proceduresPharmacyand healthcare workflows
Ability to be concise independent and provide defensible decisions in writing
Detail-orientedwith excellent communication skills (oral presentations and written) and interpersonal skills
Strong critical-thinkingcommunicationandattention to detailskills
Bonus points for:
An intermediate level of knowledge with Local State & Federal laws and regulationspertaining tohealth insurance (commercial health plans and/or dental plans)
3 years of experienceworking in the group health businesswith pharmacyas anemphasis
Experience in the healthcare industry clinical research or working clinical trials
How to be successful in this role:
Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomes
Problem- Solving: Abilitytoidentifyissues in datasets and clinical workflows and suggest data-drivensolutions
Attention to Detail:High levelof precision and accuracy in handling critical data
Who isSmartLightAnalytics
SmartLightAnalyticswas formedby a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mindSmartLightworks for self-funded employers to reduce the wasteful spend in their healthcareplanthrough our proprietary data works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.
Required Experience:
Manager
Key Skills
- IDS
- System Design
- Haskell
- PCB
- Root cause Analysis
- Technical Writing
- System Security
- Federal Aviation Regulations
- Warehouse Distribution Experience
- Encryption
- Product Development
- Contracts
About Company
Harness the power of your healthcare data Solutions to lower healthcare costs without interrupting benefits Learn More DATA LEADS THE WAY SmartLight Analytics provides independent, ongoing monitoring of your employee healthcare claims data to find and remove wasteful spend from your h ... View more
