Data Mining Specialist – Payment Integrity

This is a fully remote position, open to applicants in United States.

📋 Description

• Access client claim systems to verify claim reimbursement terms.

• Examine client contract systems or documentation for contractual reimbursement terms.

• Establish overpayment rules for data analysis.

• Analyze payer data to detect anomalies or irregular billing practices.

• Review client accounts to assess whether appropriate payments were made to providers.

• Reprice complex claims utilizing various client claims systems.

• Identify work files for audit purposes through a query process.

• Document audit results for client evaluation.

• Act as a resource for junior auditors and newly hired employees.

• Discover and develop or validate overpayment opportunities and recovery strategies.

• Serve as a subject matter expert specific to clients and programs.

• Assess procedures and suggest enhancements for processes.

• Execute responsibilities in alignment with company compliance, information security, and regulatory policies.

⛳️ Requirements

• A minimum of 5 years of experience in Payment Integrity Services.

• At least 5 to 8 years or equivalent experience in healthcare, payment integrity, or managed care contracts.

• Familiarity with Medicare, Medicaid, and Commercial claims data.

• Proficient in industry systems such as FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, and Pricers.

• Strong understanding of ICD-10, CPT, and HCPC coding guidelines.

• Experience in processing complex medical health claims.

• Knowledge of CMS Pricing Guidelines and Coding Methodologies.

• Exceptional computer skills; proficient in Excel, Word, and Outlook.

• Bachelor’s degree or equivalent work experience in Payment Integrity services.

🏝️ Benefits

• Dynamic, fast-paced, and innovative work environment.

• Opportunity to collaborate closely with highly experienced, world-class analytics consultants.

• Exposure to various aspects of clients’ businesses.

• Development of teamwork and time-management skills.

• Mentoring program with senior-level professional advisors.

• Opportunities for growth and professional development.