Senior Data Mining Auditor

Summary

Join our team as a Data Mining Senior Auditor and leverage your expertise in healthcare claims and data mining to identify medical cost savings for our clients. You will develop and implement data mining strategies, enhance existing strategies, and ensure that strategic operational and financial goals are met. This role requires a deep understanding of healthcare claims processing and the ability to translate data insights into actionable cost-saving strategies. You will work collaboratively with team members, stakeholders, and leadership to communicate findings and drive improvements. The position offers a competitive salary and a comprehensive benefits package, including healthcare, 401k matching, generous paid time off, and professional development opportunities. Remote work is supported with specific requirements for internet speed and workspace setup.

Requirements

• Seven (7) years of medical claims investigation or data mining, 5 years in a leadership role
• Demonstrated healthcare claims industry expertise
• Minimum high school diploma or GED
• Problem solving and solutions focused
• Attention to detail, and commitment to client satisfaction
• Comfortable interpreting data and developing meaningful insights, analytical mindset
• Experience with developing measures for performance and quality measurement
• Strong oral and written communication skills
• Aptitude to quickly learn software platforms such as MS SQL Server, Power BI, and other tools
• Knowledge of coding type edits and medical claim reimbursement structures and methodologies
• Proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices
• Experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing
• Knowledge in researching state and federal healthcare guidelines, e.g., Medicare and State Medicaid Programs
• Familiarity with automated medical claims payment systems and/or working knowledge of payer systems (e.g., Facets, QNXT, etc.)
• Advanced computer skills and proficiency with Microsoft Excel
• Mature professional with ability to work independently in remote work settings
• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time

Responsibilities

• Support Payment Integrity team members with development, implementation and maintenance of operational reports and dashboards
• Ensure resources are accurate, up-to-date, and can be analyzed to reveal critical insights applicable to strategic initiatives
• Produce detailed data mining reports for the Payment Integrity pillars
• Extract critical and pertinent information from the data sets that help the stakeholders understand optimal outcomes
• Effectively process and integrate primary and/or secondary data sources using database warehouse and visual applications
• Develop effective quality control processes to ensure data integrity
• Utilize data analytics to reveal critical business insights and findings
• Create and deploy PI edits and algorithms to flag suspect claims and drive savings
• Perform ad-hoc analysis to quantify and prioritize potential savings opportunities
• Triage PI referrals from local markets, HCE, Clinical Affordability to assess risk
• Build and provide sustainable audit processes that ensure overpayment findings accuracy
• Assist with concept development
• Drive opportunities to standardize process and enhance account management reporting
• Optimize technology solutions to enhance quality, minimize errors, and expedite issue resolution
• Work with team leadership to communicate challenges and recommended solutions
• Work with data mining leadership to communicate operations needs to executive leadership

Preferred Qualifications

Attainment of relevant medical billing and coding certification along with a bachelors' degree in a relevant field are both highly preferred

Benefits

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents
• 401(k) with Employer Match - Join the team and we will invest in your future
• Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays
• Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered
• Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional