Data Mining Content Ideation Senior Professional

Gainwell Technologies LLC

1d

About The Position

As a Data Mining Content Ideation Senior Professional, you will design and develop data mining concepts that identify improper payments and improve claims accuracy across dental, medical, and pharmacy billing. Using your expertise in healthcare reimbursement, regulations, and data analysis, you will translate complex policies into scalable audit and analytics solutions. You will collaborate with cross functional teams to drive innovation, support client payment integrity strategies, and help safeguard healthcare resources for the populations our clients serve.

Requirements

• 5 years of Healthcare Payment Integrity and/or Data Mining experience.
• At least 3 years of Domain Specific experience in Medical, Dental, or Pharmacy claims analysis.
• Experience in Healthcare Auditing, including Reviewing and Validating the Accuracy of Claims Data and the Accuracy of Claims Payment, is preferred.
• Experience Applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data. Recovery audit experience is preferred.

Responsibilities

• Develop and implement new data mining opportunities to identify overpayments to providers through data review and analytics across dental, medical, and pharmacy claims.
• Act as a senior member of the team and mentor lower-level analysts.
• Research industry standard guidelines, State and Federal regulations, and client billing and reimbursement policies to develop and configure improper payment algorithms.
• Review provider contracts to identify algorithms for the identification of contract-based overpayments.
• Implement current Payment Analytics concepts for new and existing clients while ensuring client policy is supportive and properly applied.
• Support the appeals, validation, and client services teams in resolving outstanding issues related to production queries.
• Ensure individual and departmental goals are consistently met or exceeded through collaboration with other team members and management.
• Review IT programming results for quality assurance and proof of concept validation.
• Document query results and prepare internal and external documentation and presentations related to new overpayment issues.
• Partner with internal operations and clinical teams to develop, implement, review, and audit protocols and internal review guidelines.
• Collaborate with engineers to develop and implement technological improvements that support the audit process.
• Contribute innovative ideas for improving existing audit processes and audit queries.

Benefits

• flexible vacation policy
• 401(k) employer match
• comprehensive health benefits
• educational assistance
• leadership and technical development academies

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees