Senior Medical Claims Accuracy Analyst

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. 

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.

Lyric’s Senior Claims Content Analysts are driven operators who take initiative to ensure smooth execution & timely delivery of internal and external deliverables.  This role partners and drives tactical focus, as the primary production point of contact for coding validation operations. Additionally, this position is responsible for leading the evaluation and development of complex medical claims content, including inpatient, outpatient, and professional claim reviews. This role will serve as a subject matter expert in medical coding, clinical documentation interpretation, and payment policy, with an emphasis on identifying inappropriate billing practices and guiding the creation or refinement of claims editing logic. This position plays a key role in both strategic content development and operational efficiency.

ESSENTIAL JOB RESPONSIBILITIES & KEY PERFORMANCE OUTCOMES

• Independently review complex professional and facility claims to assess for the presence of inappropriate coding or billing practices and determine whether an existing or potential edit should have applied. Document rationale for edit application or absence, and identify opportunities for new content development or refinement of existing edits based on claim findings.
• Translate clinical and coding research into clear, actionable logic that supports the development of new claim editing rules or policies. Ensure documentation is detailed enough for rule writers to accurately implement within the software system.
• Identify trends, inconsistencies, and coding discrepancies within claims data to inform rule development. Use findings to raise questions, refine logic, and ensure proposed edits align with real-world billing patterns and coding standards.
• Clearly articulate the conditions and criteria that must be met for a rule to trigger. Provide detailed logic descriptions that support accurate translation into system requirements by rule writers or configuration analysts.
• Deliver useful peer QA feedback on individual coding/clinical concepts including identifying gaps in research.
• Become familiar with existing system requirements/coding and reimbursement rules already available in the system.
• Compose formal written responses to provider inquiries concerning claim edits.
• Collaborate with analytics, physician, and product teams to design and validate claim edits and policies.
• Monitor regulatory and industry changes in coding guidance, reimbursement methodologies, and payer strategies. Evaluate impact and recommend adjustments to existing and future content.
• Apply independent coding judgment to resolve nuanced claim scenarios that may fall outside existing rules or policy boundaries.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Informs product strategy, influences the product roadmap, and provides feedback to product strategy leader.
• Contribute to the development and sharing of scalable methodology, process improvements and best practices.

REQUIRED QUALIFICATIONS

• Bachelor's degree in business or healthcare/related field or at least 10 years in a directly related role
• Active applicable related certificate or license (CCS, CCS-P, CPC, RHIA, )
• Minimum of seven (7) years of medical coding expertise 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 combined experience in healthcare, such as prior work in health insurance, claims processing or adjudication, or fraud, waste and abuse detection.
• Minimum of seven (7) years of experience auditing medical claims to identify improper payments as a payment integrity vendor or within a health plan’s payment integrity team.
• Minimum of seven (7) years of experience performing medical data analysis

PREFERRED QUALIFICATIONS

• Visio experience
• Expertise in researching highly-technical information on the internet
• Experience with medical coding sources such as CPT Assistant, medical association publications supporting medical coding and clinical research websites
• Extensive knowledge of claims data and associated industry-standard codes such as CPT, ICD diagnosis, revenue, bill type and admit/discharge status codes
• Knowledge of Managed Care, Medicare, and Medicaid
• Experience translating clinical and coding insights into policy or rule requirements for implementation
• Leverage experience with payment integrity and claims editing platforms to support tactical improvements in content design, workflow execution, and rule optimization across pre and post payment intervention points

• Lead collaborative case reviews and facilitate team knowledge-sharing sessions. Present findings from complex reviews and mentor junior staff on policy application, edit design, and coding best practices. Experience contributing to or leading content development for claims editing platforms.
• Familiarity with SQL or other data query languages
• Experience leading working groups or cross-functional discussions

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

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 strives to create an inclusive environment, empower employees and embrace collaborative success.