Quality Analyst – Data Mining, Payment Integrity

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

📋 Description

• Conduct quality control assessments of finalized Data Mining audit results to ensure claim accuracy, payment methods, recovery potential, and adherence to client-specific standards.

• Analyze provider agreements, fee schedules, client claims systems, pricing references, coding guidelines, and audit notes to ensure findings are substantiated and documented.

• Confirm complex claim repricing through client claims systems, pricing tools, CMS guidelines, coding resources, and procedural protocols.

• Track, evaluate, and report on error patterns, root causes, pass/fail results, and recurring issues that impact payment accuracy, audit quality, and operational efficiency.

• Suggest corrective measures, training opportunities, and initiatives for quality enhancement.

• Assess audit processes, controls, procedures, and Data Mining methods; examine query-driven audit outputs for effectiveness, consistency, efficiency, compliance, and recovery alignment.

• Collaborate with audit leadership, trainers, and subject matter experts to clarify requirements, improve processes, calibrate, initiate quality projects, update procedures, and engage in special assignments.

• Ensure that audit activities comply with client, program, regulatory, HIPAA, and company standards while upholding confidentiality.

⛳️ Requirements

• High School Diploma is mandatory.

• At least 5 years of experience in medical claims, healthcare auditing, Payment Integrity, coding, claim quality review, or related healthcare operations.

• In-depth knowledge of complex medical claim processing, provider payment methods, claim systems, and audit documentation requirements.

• Capability to interpret client specifications, provider contracts, fee schedules, coding guidelines, pricing policies, and healthcare compliance standards.

• Excellent verbal and written communication skills, capable of providing clear, professional, and actionable feedback.

• Ability to work autonomously, handle multiple priorities, meet deadlines, and ensure accuracy in a production-oriented environment.

• Comprehensive understanding of medical claims processing, healthcare reimbursement methods, provider payment logic, and overpayment recovery concepts.

• Strong knowledge of CMS pricing and reimbursement guidelines, provider contract interpretation, fee schedules, and claim payment methods.

• Familiarity with CPT, HCPCS, ICD-10-CM, and medical coding techniques; knowledge of ICD-9 is advantageous where applicable.

• Proficient in Microsoft Excel, PowerPoint, Outlook, Word, spreadsheets, databases, and data analysis tools.

• Ability to evaluate query-driven audit outputs and comprehend Data Mining logic for claim selection, overpayment detection, audit validation, and quality outcomes.

• Exceptional analytical and critical-thinking abilities to recognize patterns, root causes, quality trends, process improvement opportunities, and corrective actions.

• Strong commitment to accuracy, quality, attention to detail, confidentiality, and compliance with client, company, and healthcare standards.

• Experience in analyzing complex healthcare claims, large datasets, and payment trend data.

• Strong grasp of quality assurance principles, audit accuracy standards, QC criteria, error prevention, and quality review guidelines.

• Effective communication skills, both written and verbal, with the ability to provide constructive feedback and collaborate with auditors, leadership, trainers, and client-facing teams.

• College degree is preferred.

• CPC or other nationally recognized coding certification is preferred; relevant experience may be taken into account in lieu of certification.

• Experience in Payment Integrity, healthcare reimbursement, or overpayment recovery audits is preferred.

• Prior experience in quality review, claim audits, or audit validations is strongly preferred.

• Experience applying quality criteria, audit scorecards, accuracy standards, or structured review guidelines.

• Familiarity with healthcare claim systems and tools such as FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat/Webtrat, and relevant pricing tools.

🏝️ Benefits

• Up to 10% annual travel for team meetings and occasional client onsite engagements.

• Opportunity to collaborate closely with seasoned Healthcare consultants.

• Exposure to various aspects of clients’ businesses.

• Mentoring program offering guidance/coaching and pairing every junior-level employee with a senior-level professional advisor.

• Development in teamwork and time-management skills.

• Opportunities for growth and professional development.