Data Mining Ideation Specialist
About The Position
Under the direction of Payment Integrity leadership, the Data Mining Ideation Specialist is responsible for identifying and developing data mining audit concepts that promote payment accuracy across Medicaid, Medicare, and Commercial lines of business. This role leverages expertise in medical coding requirements, claims adjudication processes, reimbursement methodologies, and healthcare regulations to identify improper payment opportunities with a high degree of accuracy and consistency. The Data Mining Ideation Specialist collaborates with audit, analytics, and operations teams to develop new overpayment recovery opportunities, define data selection parameters, validate audit results, and support ongoing quality and education initiatives. Success in this role requires strong analytical skills, extensive coding knowledge, attention to detail, and the ability to interpret complex healthcare reimbursement policies and regulations.
Requirements
- Minimum of five (5) years of complex claims processing, claims auditing, medical coding, or payment integrity experience within the healthcare industry.
- Knowledge of Medicare, Medicaid, and Commercial health insurance plans and reimbursement methodologies.
- Mastery of CPT, HCPCS, and ICD coding standards and guidelines.
- Current coding certification required, including one of the following: AAPC Certified Professional Coder (CPC), AAPC Certified Outpatient Coder (COC), AHIMA Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT).
- Expert understanding of medical claim coding and its impact on claim reimbursement and payment accuracy.
- Strong knowledge of healthcare claim processing, billing regulations, reimbursement methodologies, and provider contracting principles.
- Knowledge of legal, regulatory, compliance, and documentation requirements related to medical coding and billing practices.
- Experience interpreting reimbursement policies, payer edits, and regulatory guidance, including: National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), NCCIP Procedure-to-Procedure (PTP) Edits, Medically Unlikely Edits (MUEs), DRG, APC, and EAPG reimbursement methodologies, Multiple Surgery Reductions, Three-Day Payment Window regulations, Eligibility and Coordination of Benefits (COB) requirements.
- Advanced proficiency in Microsoft Excel and data analysis techniques.
- Strong analytical, organizational, and problem-solving skills.
- Excellent verbal, written, and interpersonal communication skills.
- Exceptional attention to detail and commitment to quality.
- Ability to effectively manage multiple priorities in a fast-paced environment.
Nice To Haves
- Prior experience developing payment integrity, data mining, or reimbursement audit concepts strongly preferred.
- Experience with Python, SQL, or other data analysis and reporting tools.
- Clinical healthcare experience or background.
- Experience translating complex technical concepts into user-friendly training materials and documentation.
- Previous experience within the Payment Integrity industry.
- Knowledge of EDI transactions, including 837 and 835 claim formats.
- Experience using coding and audit tools such as 3M, WebStrat, Encoder, or similar platforms.
- Demonstrated ability to collaborate effectively across cross-functional teams.
- Proficiency with Microsoft Outlook, Word, Excel, and related business applications.
- Ability to work independently while managing multiple projects and changing priorities.
Responsibilities
- Leverage Federal, State, local, and client-specific regulations, contracts, policies, and reimbursement guidelines to identify new data mining audit opportunities.
- Develop and define data selection criteria and audit logic requirements to ensure accurate claim identification.
- Validate audit outputs and results to ensure integrity, consistency, and payment accuracy.
- Serve as a subject matter expert for designated clients and audit concepts.
- Assist with obtaining client approvals and responding to client requests related to audit concept development and performance.
- Develop and maintain concept-specific training materials for audit staff and operational teams.
- Monitor audit performance and identify opportunities for ongoing improvements, enhancements, and logic revisions.
- Maintain expertise in CPT, HCPCS, and ICD-10 coding guidelines, healthcare reimbursement methodologies, and claim submission requirements.
- Collaborate with analytics, operations, audit, and client services teams to identify and implement new payment integrity opportunities.
- Research emerging healthcare regulations, coding updates, and reimbursement policy changes that may impact audit development.
- Support quality assurance initiatives and provide guidance regarding audit accuracy and concept implementation.
- Perform additional projects and duties as assigned.
Benefits
- Medical, Dental, and Vision Insurance
- 401(k) Retirement Plan
- Life and Disability Insurance
- Paid Time Off and Company Holidays
- Flexible Spending Accounts (FSA)
- Employee Assistance Program (EAP)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
