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
SmartLight 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.
Top Skills
What We Do
SmartLight Analytics was formed by a group of industry insiders driven to make a meaningful impact on the rising cost of employee healthcare. Using our statistical, clinical, fraud detection, coding and claims expertise we deliver the most complete wasteful spend reduction solution directly to self-funded employers.
SmartLight utilizes proprietary inferential analytics customized to your employee population, followed by expert clinical review on 100% of your medical claims. Our team partners with your TPA to implement solutions resulting in a lower per employee healthcare spend. We let your data tell us where to look without any preconceived notions about what the errors are beforehand.
Our approach is low-touch and involves zero employee involvement. SmartLight consistently delivers a higher ROI compared to other cost reduction solutions on the market.
