Lead Pharmacy Payment Integrity Analyst

Position Overview: 

The Pharmacy Payment Integrity Analyst plays a critical role in analyzing and interpreting Pharmacy 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 you’ll drive:

• You’ll identify, waste and inaccurate Pharmacy claims

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

• You’ll foster a culture of learning, refinement, and ethical excellence to create high quality, evidence-backed referrals that reduce health insurance costs. 

What you’ll do: 

• Identify Pharmacy billing activities leading to improper payments. This work involves reviewing 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 

• 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, 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: 

• 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

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 with pharmacy as an emphasis 

• 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 

SmartLightAnalyticswas formedby a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind,SmartLightworks 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.