Payment Integrity Analyst II at SmartLight Analytics

The Payment Integrity Analyst II plays a critical role in analyzing and interpreting healthcare 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 youll drive:Youll identify investigate and report on wasteful and inaccurate spend in healthcare claimsYoull work with industry leading AI predictive analytics and automation platforms to uncover patterns and drive smarter decisions.Youll foster a culture of learning refinement and ethical excellence to create high quality evidence backed referrals that reduce health insurance costs.What youll do: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 customers carrier or third-party administratorReview claims data and conduct analysis to look for patterns of potential FWA and other improper paymentsUtilizing 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 channelsConduct data analysis to review claim and case historyReviews 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 datasetsWhat you bring:Bachelors degree or 8 10 years of equivalent work experience in healthcare administration billing claims adjudication clinical auditing payment integrity operations and/or healthcare reimbursementRN CPC CCS or other relevant clinical/coding certifications strongly preferredStrong knowledge of clinical terminology medical procedures and healthcare workflowsAbility to be concise independent and provide defensible decisions in writingDetail-oriented with excellent communication skills (oral presentations and written) and interpersonal skillsStrong critical-thinking communication and attention to detail skillsBonus 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 or experience in a healthcare providers practiceExperience in the healthcare industry clinical research or working clinical trialsHow to be successful in this role:Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomesProblem- Solving: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutionsAttention to Detail: High level of precision and accuracy in handling critical dataWho is SmartLight AnalyticsSmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind SmartLight works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes. Required Experience:Manager Key Skills IDS,System Design,Haskell,PCB,Root cause Analysis,Technical Writing,System Security,Federal Aviation Regulations,Warehouse Distribution Experience,Encryption,Product Development,Contracts Employment Type : Full-Time Experience: years Vacancy: 1