• Investigate and validate other insurance coverage, resolving conflicting eligibility information. • Establish the correct order of liability (primary vs. secondary payer) to prevent and recover improper claim payments. • Perform hands-on casework in a high-volume environment including outreach, documentation, and system updates. • Apply analytical skills to interpret claims and eligibility data, identify trends, and recommend process improvements for COB program.

• 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. • 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 terms) and drive cases to a clear, audit-ready determination; escalate edge cases per policy. • 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. • 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. • 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 responses) and drive cases to a clear, audit-ready determination.

• Manage and coordinate the overall Solutions Design process, ensuring clinical protocols are accurately mapped to Clario software solutions. • Gather and document requirements, defining study‑specific design components. • Represent the Solutions Design team as a subject matter expert in client meetings. • Create and maintain specifications for study implementations of Clario products and services. • Ensure alignment between trial data capture, data delivery, and database structures. • Collaborate with Clinical Systems Translation & Licensing to confirm correct versions of copyrighted questionnaires. • Support Solutions Validation/Quality Control testing by resolving design‑related defects. • Partner with cross‑functional teams to troubleshoot study issues beyond startup. • Contribute to interdepartmental process improvement initiatives. • Collaborate with Clinical Project Management to ensure sponsor expectations are met. • Participate in, and occasionally lead, internal and external design milestone meetings. • Represent Solutions Design during client audits, clearly describing processes, standards, and best practices. • Partner with Business Development and Project Management to review proposals and protocols for new studies. • Configure systems based on approved configurational documents. • Map, configure, and maintain automated workflows using low-code/no-code platforms. • Build and customize user interfaces, forms, and data collection fields to ensure accurate data capture. • Analyze existing business processes to identify opportunities for automation. • Conduct user acceptance testing (UAT) and validate workflow logic. • Ensure seamless integration of workflows across various platforms and applications. • Document technical processes and create reports/dashboards based on captured data.

• Manage, maintain, and regularly update payer fee schedules and methodology in rate management system for assigned payer contracts • Monitor effective dates, rate changes, and contract modifications • Support validation efforts to ensure payer reimbursement aligns with contracted terms • Identify changes to payer information via newsletters, bulletins, policy updates, and payer portals • Monitor communication channels and share updates with Payer Relations leads • Manage field-facing payer information to optimize accurate handling of patient registration • Partner with internal teams to ensure accurate and timely contract alignment and payment accuracy • Act as the subject matter expert for the availability and effectiveness of payer communication channels • Build and maintain strong working relationships with internal stakeholders and external payer counterparts • Assist in researching and resolving payer related operational issues • Maintain documentation repositories for payer policies, requirements, and fee schedules