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SmartLight Analytics · 1 month ago

Payment Integrity Analyst II

United States

Full-time

Remote

Senior Level, Lead/Staff

8+ years exp

SmartLight Analytics is focused on reducing wasteful spending in healthcare for self-funded employers through data analysis. The Payment Integrity Analyst II plays a critical role in analyzing healthcare data to improve patient outcomes and ensure accurate claims processing while preventing overpayments.

AnalyticsHealth CareInformation TechnologySoftware

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 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

Qualification

Healthcare data analysisClaims adjudicationClinical auditingHealthcare reimbursementClinical terminologyData discrepancy resolutionIndependent decision-makingCommunication skillsCritical thinkingAttention to detailProblem-solvingInterpersonal skills

Required

Bachelor's degree or 8 – 10 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

Preferred

RN, 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