Lead Pharmacy Payment Integrity Analyst

Position Overview ThePharmacyPayment IntegrityAnalystplays a critical role in analyzing and interpretingPharmacydatatoprovideactionable insights for improving patient outcomes,optimizingclinical workflows, and supporting healthcare decision-making.Thispositionensuresaccurateclaims processing, policy interpretation, and regulatory alignment to prevent overpayments and cost-effective healthcare payments. Whatyou’lldrive You’llidentify, wasteand inaccuratePharmacyclaims You’llwork withindustry leadingAI, 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. Whatyou’lldo IdentifyPharmacybillingactivities leading to improper payments. This work involves reviewingPharmacyclaims,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.andutilizesdata analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State sites,etc. Identifyand resolve issues related to data discrepancies, missing data, or inconsistencies within clinical datasets What you bring Bachelor's degreeor4–6years ofequivalent work experienceinhealthcare administration, billing,Pharmacyclaims adjudication,Pharmacyauditing,payment integrityoperationsand/or healthcare reimbursement, CPhT,CPC, CCS or other relevant clinical/Pharmacy/coding certificationsstronglypreferred. Strongknowledge of clinical terminology, medical procedures,Pharmacyand healthcare workflows Ability to be concise, independent and provide defensible decisions in writing Detail-orientedwith excellent communication skills (oral presentations and written) and interpersonal skills Strong critical-thinking,communicationandattention to detailskills Bonus points for An intermediate level of knowledge with Local, State & Federal laws and regulationspertaining tohealth insurance (commercial health plans and/or dental plans) 3+ years of experienceworking in the group health businesswith pharmacyas anemphasis 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: Abilitytoidentifyissues in datasets and clinical workflows and suggest data-drivensolutions Attention to Detail:High levelof precision and accuracy in handling critical data #J-18808-Ljbffr SmartLight Analytics