Data Mining Specialist (Payment Integrity)

EXL•United States,

6d•$93,900 - $134,100

About The Position

The Data Mining Specialist (Payment Integrity) identifies, develops, and implements effective data-mining queries. The role requires knowledge of Medicare, Medicaid, and Commercial claims, and experience navigating multiple claims payment systems. The specialist analyzes complex claims to identify payment anomalies and recovery opportunities, then translates findings into accurate, actionable data-mining concepts that can be adapted to different client environments. The position reviews client reimbursement terms and accounts, creates overpayment rules, reprices complex claims, and documents audit findings for clients. It also supports junior auditors and new employees, serves as a program- and client-specific subject matter expert, and recommends process improvements while following company compliance, information security, and regulatory policies. The posted base salary range is $93,900–$134,100 per year. EXL describes its environment as fast-paced and innovative and mentions opportunities to work with experienced analytics consultants, learn about client businesses, receive mentoring and coaching, and pursue professional growth.

Requirements

At least 5 years of employment within Payment Integrity Services.
At least 5–8 years, or equivalent work experience, in healthcare, payment integrity, or managed care contracts.
Experience with Medicare, Medicaid, and Commercial claims data.
Experience with industry systems, including FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, and Pricers.
Sound knowledge of ICD-10, CPT, and HCPC coding guidelines.
Experience processing complex medical health claims.
Knowledge of CMS Pricing Guidelines and Coding Methodologies.
Attention to detail and ability to problem-solve.
Excellent computer skills and proficiency in Excel, Word, and Outlook.
Excellent interpersonal and communication skills.
Ability to train and delegate.
Ability to prioritize tasks.
Excellent organizational skills.
Bachelor’s degree or equivalent work experience in Payment Integrity services.

Responsibilities

Access client claim systems to validate claim reimbursement terms as needed.
Routinely review client contract systems or files for contractual reimbursement terms.
Create overpayment rules for data mining.
Analyze payer data and identify anomalies or aberrant billing practices.
Review client accounts to determine whether providers were paid correctly.
Reprice complex claims using multiple client claims systems.
Identify work files to be audited through a query process.
Document audit findings to share with the client.
Serve as a resource for junior auditors and new employees.
Identify and develop or validate new overpayment opportunities and recovery concepts.
Serve as a client- and program-specific subject matter expert in internal and external settings when called upon.
Evaluate procedures for efficiency and accuracy and recommend process improvements.
Perform job functions in accordance with company compliance, information security, and regulatory policies, procedures, and programs.