Lead Pharmacy Payment Integrity Analyst

Identify Pharmacy billing activities leading to improper payments. Review Pharmacy claims, 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. Utilize 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. Review claims history, provider files, etc. and utilize 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. Requirements Bachelor's degree or 4 – 6 years of equivalent work experience in healthcare administration, billing, Pharmacy claims adjudication, Pharmacy auditing, payment integrity operations and/or healthcare reimbursement, CPhT, CPC, CCS or other relevant clinical/Pharmacy/coding certifications strongly preferred. Strong knowledge of clinical terminology, medical procedures, Pharmacy 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. #J-18808-Ljbffr Jobtailor