Lead Pharmacy Integrity Analyst

Position Overview

The Pharmacy Payment  Integrity Analystplays a critical role in analyzing and interpreting

Pharmacydatatoprovideactionable insights for improving patient outcomes,optimizingclinical workflows, and supporting healthcare decision-making.

Thispositionensuresaccurateclaims processing, policy interpretation, and regulatory alignment to prevent over payments and cost-effective healthcare payments.

• You’ll identify, wasteand inaccuratePharmacyclaims

• You’llwork with industry leading
  
  AI, predictive analytics, and automation platforms to uncover patterns and drive smarter decisions.

• You’llfoster a culture of learning, refinement, and ethical excellenceto create high quality,evidence-backedreferrals that reduce health insurance costs.

• Identify Pharmacybillingactivities leading to improper payments. This work involves reviewing
  
  Pharmacyclaims,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 over payment through designated channels

• Conduct data analysis to review claim and case history

• Reviews claims history,provider files,etc.andutilizesdata 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

• Bachelor's degreeor4–6years of equivalent work experienceinhealthcare administration, billing,Pharmacyclaims adjudication,Pharmacyauditing,payment integrityoperationsand/or healthcare reimbursement,

• CPhT,CPC, CCS or other relevant clinical/Pharmacy/coding certificationsstronglypreferred.

• Strong knowledge of clinical terminology, medical procedures,Pharmacyand 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,communicationandattention to detailskills

• An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining tohealth insurance (commercial health plans and/or dental plans)

• 3+ years of experience working in the group health business with pharmacyas an emphasis

• Experience in the healthcare industry, clinical research or working clinical trials

• 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-driven solutions

• Attention to Detail:
  
  High levelof precision and accuracy in handling critical data

Smart Light Analyticswas  formedby a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind,Smart Lightworks for self-funded employers to reduce the wasteful spend in their healthcareplanthrough our proprietary data analysis.

Ourprocess works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.