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Lyric, formerly ClaimsXten, is a leading healthcare technology company, committed to simplifying the business of care. Over 30 years of experience, dedicated teams, and top technology help deliver more than $14 billion of annual savings to our many loyal and valued customers—including 9 of the top 10 payers across the country. Lyric’s solutions leverage the power of machine learning, AI, and predictive analytics to empower health plan payers with pathways to increased accuracy and efficiency, while maximizing value and savings. Lyric’s strong relationships as a trusted ally to customers resulted in recognition from KLAS as “true partner” and “excellent value for investment,” with a top score for overall customer satisfaction and A+ likelihood to recommend in their October 2023 Payment Integrity and Accuracy Report. Discover more at Lyric.ai .

The post pay opportunity role is an external customer facing position responsible for maintaining and expanding customer value from Lyric post pay solutions by increasing adoption of Lyric content. This role will be an internal partner to other Lyric team members to continue to develop content and models to drive additional customer value. The candidate will also be a catalyst for operation excellence by executing functions with focus on accuracy, quality and meeting KPI objective; collaborating with operation leaders for process improvements.

• Analyze claim inventory from identification to resolution. Develop client facing model overviews and analysis. Collaborate with team to configure client specific business rules.

• Develop and execute data mining audits that identify claims not paid in accordance with Client’s payment policy or Provider’s contract language. Partner with team to validate claim overpayments based on reimbursement methodology, claim coding details, and the audit’s edit parameters.

• Compile sample claims and supporting documentation for Client review and approval. Maintain a library that includes instructions for validating specific audit concepts.

• Collaborate with internal team members and clients to resolve provider disputes and inquiries.

• Assist technical teams in developing model features and parameters to identify improperly paid medical claims based upon new model concepts. Analyze and identify opportunities to improve model performance

• Maintain productivity goals and standards set by the department.

• Train, QC check, monitor work of less tenured team members.

REQUIRED QUALIFICATIONS

Required (quantifiable from resume/application):

• 5+ years of combined experience in healthcare, such as prior work in health insurance, claims processing or adjudication, or fraud, waste and abuse detection

• 5+ Years’ experience auditing medical claims to identify improper payments as a Payment Integrity Vendor or within a Health Plan’s Payment Integrity team.

• 5+ years of experience performing data analytics with large data sets

• Working knowledge of medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, and NDC, as well as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS

• Knowledge of Managed Care, Medicare, or Medicaid

PREFERRED QUALIFICATIONS

• Bachelors degree in business or healthcare/related field

• Creative thinker with an entrepreneurial spirit

• Strong verbal and written communication skills

• Experience in various claim payment methodologies for professional, facility, and ancillary providers

• Deep understanding of payment integrity auditing concepts

• Proficient with SQL

*The US base salary range for this full-time position is:

$119,439.36 - $179,159.04

The specific salary offered to a candidate may be influenced by a variety of factors including but not limited to the candidate’s relevant experience, education, and work location. Please note that the compensation details listed in US role postings reflect the base salary only, and does not reflect the value of the total rewards compensation. *

Lyric is an Equal Opportunity Employer that drives superior business results by understanding and leveraging diversity. We strive to maximize the productivity and performance of our employees by fostering a winning team spirit and high personal accountability. Everyone is encouraged to respond including women, people of color, veterans, people with disabilities, all lifestyles, beliefs and generational diversity.