Payment Integrity Analyst - Data Mining
Lyric is an AI-first, platform-based healthcare technology company, committed to simplifying the business of care by preventing inaccurate payments and reducing overall waste in the healthcare ecosystem, enabling more efficient use of resources to reduce the cost of care for payers, providers, and patients. Lyric, formerly ClaimsXten, is a market leader with 35 years of pre-pay editing expertise, dedicated teams, and top technology. Lyric is proud to be recognized as 2025 Best in KLAS for Pre-Payment Accuracy and Integrity and is HI-TRUST and SOC2 certified, and a recipient of the 2025 CandE Award for Candidate Experience. Interested in shaping the future of healthcare with AI? Explore opportunities at lyric.ai/careers and drive innovation with #YouToThePowerOfAI.
Applicants must already be legally authorized to work in the U.S. Visa sponsorship/sponsorship assumption and other immigration support are not available for this position.
JOB SUMMARY
The Payment Integrity Analyst (Data Mining) supports the Data Mining (DM) program by investigating payment errors due to incorrect processing of payment policies, contract terms, billing and/or coding errors to prevent and recover improper claim payments. This role performs hands-on casework in a high-volume environment including outreach, documentation, and system updates, while applying analytical skills to interpret claims and eligibility data, identify trends, and recommends process improvements that improve accuracy for the data mining program.
ESSENTIAL JOB RESPONSIBILITIES & KEY PERFORMANCE OUTCOMES
Investigation and verification
-
Review, prioritize, and independently work assigned DM leads (automated and manual), including moderate-to-complex and high-dollar cases, to determine verification steps and next actions.
-
Investigate and validate payment terms (Inpatient, Outpatient, Professional, Ancillary) using internal systems, payer portals, contracts, and other approved data sources.
-
Apply payment policies, contract terms and coding guidelines, including CMS and AMA guidance as applicable, to determine the correct reimbursement and document the rationale for the payment determination.
-
Reconcile discrepancies across sources (contract data and paper forms, conflicting policy and contract terns) and drive cases to a clear, audit-ready determination; escalate edge cases per policy.
Collaboration, documentation, and system updates
-
Analyze claim inventory from identification to resolution. Assist in developing concept overviews and analysis. Collaborate with team to configure client specific business rules.
-
Assist in compiling sample claims and supporting documentation for Client review and approval. Maintain a library that includes instructions for validating specific audit concepts.
-
Create clear, detailed, and accurate case notes that capture verification steps, evidence, and outcomes in internal tools to support audits and downstream recovery/reprocessing.
Payment integrity support & Operational excellence
-
Provide validated DM outcomes that support downstream payment integrity activities (recovery, reprocessing, adjustments) with minimal rework.
-
Prepare and evaluate documentation needed for inquiries, disputes, and appeals related to determinations, as assigned.
-
Meet or exceed established productivity, turnaround time, and quality/audit standards while managing a high-volume case queue.
Analytical contribution
-
Track outcomes and error categories, identify root causes of recurring DM issues and false positives, and recommend opportunities to streamline research, improve data quality, and reduce incorrect payments.
-
Use Excel and other tools to support ad hoc analysis (e.g., trend review, inventory quality checks, and performance insights); partner with stakeholders to clarify requirements and improve workflows.
-
Reconcile discrepancies across sources (eligibility feeds, member/group data, claim history, and third-party respons