Senior Manager – Data Mining, Exploratory Intelligence

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

📋 Description

• Lead in-depth analysis of claims data to uncover utilization trends, anomalies, and instances of potential overpayment or inappropriate claims.

• Utilize extensive knowledge of billing regulations, coding, reimbursement processes, and workflows to direct data exploration and investigative initiatives.

• Conduct reverse engineering of claims outcomes to identify the underlying causes of payment discrepancies and system functionalities.

• Convert operational and claims insights into concise use cases, concepts, and solution proposals for analytics and product teams.

• Collaborate closely with analytics, product, and strategy teams to ensure that solutions are in sync with actual claims operations.

• Validate data-driven insights against real-world claims and payment circumstances.

• Effectively communicate insights, risks, and opportunities to both technical and non-technical audiences.

• Assist in the continuous improvement and expansion of claims monitoring and overpayment detection capabilities.

⛳️ Requirements

• Over 10 years of experience in operations with a strong emphasis on claims adjudication and payment integrity.

• Extensive background in Medicare, Medicaid, and/or commercial platforms.

• Proven expertise in comprehensive claims review, auditing, and payment integrity.

• Demonstrated capability to identify patterns, anomalies, and inappropriate payments within large claims datasets.

• Strong analytical skills with the ability to connect operations and data science.

• Experience working with cross-functional teams (analytics, product, strategy, compliance).

• Exceptional communication abilities with a knack for clearly explaining complex claims concepts.

• Previous involvement in payment integrity, Special Investigations Unit (SIU), or recovery initiatives.

• Background in supporting or designing claims analytics or data mining initiatives.

• Familiarity with common coding systems, authorization models, and provider billing practices.

• Bachelor's Degree.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Generous paid time off and flexible working arrangements.

• Opportunities for professional development and career advancement.

• Supportive and inclusive work environment.