Payment Integrity Analyst II
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Job Location:
Monthly Salary:
Posted on:
Yesterday
Vacancies:
1 Vacancy
Job Summary
The Payment Integrity Analyst II 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.
What youll drive:
Youll identify investigate and report on wasteful and inaccurate spend in healthcare claims
Youll work with industry leading AI predictive analytics and automation platforms to uncover patterns and drive smarter decisions.
Youll foster a culture of learning refinement and ethical excellence to create high quality evidence backed referrals that reduce health insurance costs.
What youll do:
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 customers carrier or third-party administrator
Review claims data and conduct analysis to look for patterns of potential FWA and other 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 you bring:
Bachelors degree or 8 10 years of equivalent work experience in healthcare administration billing claims adjudication clinical auditing payment integrity operations and/or healthcare reimbursement
RN CPC CCS or other relevant clinical/coding certifications strongly preferred
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
Bonus points for:
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 providers practice
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: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutions
Attention to Detail: High level of precision and accuracy in handling critical data
Who is SmartLight Analytics
SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind SmartLight works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process 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
