Data Mining Senior Auditor

MedReview•New York, NY

7d•$85,000 - $90,000•Remote

About The Position

MedReview is seeking a Data Mining Senior Auditor to join its Payment Integrity team. The role identifies healthcare cost-savings opportunities through data mining strategies, claims analysis, audit development, and payment integrity initiatives. The auditor uses healthcare claims expertise to uncover overpayments, develop audit concepts, enhance savings strategies, and support health plan clients’ operational and financial objectives. This position requires strong analytical skills, knowledge of healthcare claims processing and reimbursement methodologies, and the ability to turn complex data into actionable insights that produce measurable savings. The role develops and maintains data mining strategies, payment integrity edits, algorithms, and auditing methodologies; analyzes claims and develops audit concepts; prepares reports, dashboards, and performance metrics; and performs analyses to quantify and validate savings opportunities. It also establishes quality controls and repeatable audit processes, improves technology solutions and workflows, supports process standardization, and collaborates with clinical, operations, analytics, leadership, and health plan stakeholders. The position is remote and requires a high-speed internet connection, a dedicated workspace that protects PHI and HIPAA-sensitive information, and the ability to work at a computer and use a keyboard for extended periods. The salary range is $85,000–$90,000 annually, commensurate with experience.

Requirements

High school diploma or GED required.
Seven or more years of healthcare claims investigation, payment integrity, or data mining experience.
Five or more years of leadership experience within healthcare auditing, payment integrity, or related functions.
Demonstrated expertise in healthcare claims processing, reimbursement methodologies, and payment integrity concepts.
Strong analytical, critical-thinking, and problem-solving skills.
Experience developing performance measures and quality assurance methodologies.
Strong verbal and written communication skills.
High attention to detail and commitment to client satisfaction.
Advanced proficiency with Microsoft Excel.
Ability to quickly learn and use SQL Server, Power BI, and related analytics platforms.
Knowledge of coding edits, reimbursement methodologies, and medical claims payment systems.
Understanding of medical terminology, procedures, diagnoses, treatment practices, and claims adjudication processes.
Experience applying coding guidelines, billing regulations, and federal and state healthcare policies.
Knowledge of Medicare, Medicaid, and commercial payer reimbursement requirements.
Experience working with healthcare payer systems such as Facets, QNXT, or similar claims platforms.
Ability to work independently in a remote environment.
High-speed internet connection (100 Mbps recommended).
Dedicated workspace with minimal interruptions and the ability to protect PHI and HIPAA-sensitive information.
Ability to work at a computer and utilize a keyboard for extended periods.

Nice To Haves

Bachelor’s degree in Health Information Management, Healthcare Administration, Data Analytics, Business, or a related field.
CPC, CCS, CPMA, RHIA, RHIT, or other relevant coding, billing, or auditing certification.
Experience with SQL, data warehousing, Power BI, and advanced healthcare analytics tools.
Experience developing healthcare payment integrity concepts resulting in measurable client savings.
Experience working with health plans, third-party administrators, or payment integrity organizations.

Responsibilities

Develop, implement, and maintain data mining strategies to identify claims overpayments and cost-saving opportunities.
Create and deploy payment integrity edits, algorithms, and auditing methodologies to flag suspect claims and drive recoveries.
Analyze claims to identify trends, patterns, and opportunities for savings initiatives.
Assist in developing new audit concepts and payment integrity programs.
Evaluate and enhance existing savings strategies to improve client outcomes.
Produce data mining reports and analyses for Payment Integrity operations.
Extract and interpret information from large healthcare claims datasets to inform business and operational decisions.
Develop and maintain operational reports, dashboards, and performance metrics.
Use data analytics tools to identify business insights and opportunities.
Perform ad hoc analyses to quantify, prioritize, and validate savings opportunities.
Develop and maintain quality control processes that ensure data accuracy, consistency, and integrity.
Build sustainable audit processes so overpayment findings are accurate, defensible, and repeatable.
Optimize technology solutions and workflows to improve efficiency, reduce errors, and support issue resolution.
Identify opportunities to standardize processes and improve operational reporting.
Support process improvement initiatives across the Payment Integrity function.
Collaborate with Payment Integrity, Clinical, Operations, and Analytics teams on organizational objectives.
Assess and triage referrals from health plans, Clinical Affordability teams, healthcare economics departments, and other stakeholders.
Communicate operational challenges, findings, and recommendations to leadership.
Partner with Data Mining leadership to communicate operational needs and strategic opportunities to executive leadership.
Support cross-functional initiatives that improve audit performance and maximize client savings.