Senior Data Mining Analyst

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

📋 Description

• Oversee pre and post-payment claim assessments to detect inaccuracies in payments leveraging reimbursement and contract knowledge.

• Examine and interpret provider agreements to ensure payments are consistent with negotiated terms, methodologies, and payer regulations.

• Work closely with engineering and data science teams to convert business and reimbursement logic into analytical and automation frameworks.

• Investigate and document evolving reimbursement and contract trends, coverage regulations, and billing practices to support concept development.

• Convert intricate reimbursement and contract situations into structured rules and business logic for execution.

• Evaluate claim-level data to identify the root causes of overpayments or erroneous denials, and propose corrective measures.

• Maintain a strong understanding of CMS and commercial payer reimbursement protocols.

• Assist in quality reviews, concept validation, and process enhancement initiatives.

⛳️ Requirements

• Over 5 years of experience in healthcare data mining or claims editing within provider, payer, or vendor settings.

• Profound knowledge of provider contracts, including rate structures, carve-outs, and reimbursement methodologies.

• In-depth understanding of claims processing, coding, billing, and payment logic relevant to CMS and commercial payers.

• Demonstrated ability to identify improper payment patterns, ascertain root causes, and discover opportunities for correction.

• Excellent investigative and deductive reasoning capabilities; adept at linking policy, data, and contractual details.

• Comfortable collaborating closely with technical teams to steer the implementation of business logic.

• Self-motivated, detail-oriented, and able to thrive in a fast-paced, evolving environment.

• Preferred coding certification (e.g., CPC, CCS, or equivalent).

• Preferred working proficiency in SQL for data exploration and validation.

• Experience in cross-functional R&D or innovation teams concentrating on healthcare payment integrity is preferred.

🏝️ Benefits

• Work from anywhere in the US! Machinify embraces a digital-first approach.

• Comprehensive Medical/Dental/Vision plans.

• Flexible Spending Account/Health Savings Account options.

• Tuition reimbursement program.

• Competitive salary package.

• 401(k) plan with company match.

• Additional health and wellness benefits and perks.

• A flexible and trusting environment where you will feel empowered to perform your best work.