Payment Integrity Analyst - Coordination of Benefits

📋 Description

• • Join Lyric, a pioneering AI-first healthcare technology company, at the forefront of simplifying the business of care. We are dedicated to preventing inaccurate payments and reducing waste within the healthcare ecosystem, ultimately enabling more efficient resource utilization and lowering costs for payers, providers, and patients. With a legacy of 35 years as a market leader in pre-pay editing, backed by dedicated teams and cutting-edge technology, Lyric is recognized for its excellence, including being named 2025 Best in KLAS for Pre-Payment Accuracy and Integrity, and holding HI-TRUST and SOC2 certifications. We are also honored recipients of the 2025 CandE Award for Candidate Experience. If you are passionate about shaping the future of healthcare with AI, explore opportunities at lyric.ai/careers and drive innovation with #YouToThePowerOfAI.
• • As a Payment Integrity Analyst specializing in Coordination of Benefits (COB), you will play a critical role in safeguarding the financial integrity of our healthcare operations. Your primary responsibility will be to meticulously investigate and validate other insurance coverage, resolve complex eligibility discrepancies, and definitively establish the correct order of liability between primary and secondary payers. This proactive approach is essential to prevent and recover improper claim payments, ensuring that healthcare funds are utilized appropriately.
• • This is a hands-on casework role within a dynamic, high-volume environment. You will be instrumental in conducting thorough investigations, performing essential outreach to gather information, meticulously documenting your findings, and updating relevant systems with verified data. Your analytical acumen will be crucial in interpreting intricate claims and eligibility data, identifying emerging trends, and proposing actionable process improvements that enhance the accuracy and efficiency of our COB program.
• • Key responsibilities include reviewing and prioritizing assigned COB leads, whether generated automatically or manually, to determine the most effective verification steps and subsequent actions. You will delve into investigating and validating crucial coverage details, including payer information, plan types, subscriber relationships, policy indicators, and effective/termination dates. This validation will leverage a variety of resources such as internal systems, payer portals, Explanation of Benefits (EOBs), claim responses, and other approved data sources.
• • A core aspect of your role will involve applying established COB rules and guidelines, including those mandated by CMS and NAIC where applicable, to accurately determine the correct order of liability. You will be responsible for clearly documenting the rationale behind each primacy determination, ensuring transparency and auditability.
• • You will actively engage in outreach activities, contacting insurance carriers, employers, clearinghouses, providers, and other relevant third parties. The purpose of this outreach is to confirm or clarify coverage information and obtain necessary supporting evidence to substantiate your findings.
• • Meticulous documentation is paramount. You will create clear, detailed, and accurate case notes within our internal tools, capturing every verification step, piece of evidence obtained, and the ultimate outcome. This documentation is vital for supporting audits and facilitating downstream recovery and reprocessing efforts.
• • System updates will be a regular part of your workflow. You will update eligibility and COB records, as well as coordination rules, based on the verified information. Ensuring these updates are applied correctly is crucial for minimizing downstream adjudication errors and reducing operational friction.
• • Your validated COB outcomes will directly support critical downstream payment integrity activities, including recovery, reprocessing, and adjustments, with a focus on minimizing the need for rework.
• • You will also be responsible for preparing and evaluating documentation required for inquiries, disputes, and appeals related to your determinations, as assigned.
• • Success in this role requires meeting and exceeding established productivity, turnaround time, and quality/audit standards, all while effectively managing a high-volume case queue.
• • Beyond casework, you will contribute analytically by tracking outcomes and error categories, identifying the root causes of recurring COB issues and false positives. This insight will be used to recommend opportunities for streamlining research processes, improving data quality, and ultimately reducing incorrect payments.
• • You will utilize tools such as Excel and others to support ad hoc analyses, including trend reviews, inventory quality checks, and performance insights. Partnering with stakeholders to clarify requirements and enhance workflows will be essential.
• • A key analytical task involves reconciling discrepancies across various data sources, such as eligibility feeds, member/group data, claim history, and third-party responses, driving cases to a clear, audit-ready determination.