Payment Integrity Data Mining Ideation SME
$80,000–$100,000 year
Remote · United States
Job Summary
REMOTE role focusing on leveraging medical coding and claims data expertise to design data mining audits that promote payment accuracy across Medicaid, Medicare, and Commercial lines. Collaborates with audit, analytics, and operations teams to identify overpayment opportunities, define data selections, and validate results. Provides training for production audit staff and supports education and quality initiatives. Maintains expertise in CPT, HCPCS, and ICD-10 coding guidelines, reimbursement methodologies, and contract/regulatory requirements. Aims to generate logic specifications for new concepts monthly and ensure timely inquiries and updates to stakeholders.
Required Qualifications
- 5+ years of complex claims processing and/or coding auditing experience in the health insurance industry
- Knowledge of all payer types including Medicare, Medicaid, and Commercial plans
- Prior experience in payment integrity audit development is highly preferred
- Mastery of CPT, HCPCS, and ICD coding standards
- Current Coding Certification: AAPC CPC, COC, CCS or RHIT designation
- Expert level understanding of medical claim coding and its impact on claim payments, including reimbursement methodologies
- Ability to develop data mining audits, apply regulatory standards, and contractual requirements
- Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures and documentation
- Knowledge of health insurance operations, claims processing, billing, reimbursement, or provider contracting
- Prior experience in payer edit development, and/or reimbursement policy experience (e.g., CMS policies, NCDs/LCDs, NCCI Edits, DRG/APC/EAPG)
- Experience with data analysis tools (Excel); desirable: Python or SQL
- Clinical background or experience; demonstrated ability translating technical jargon to non-technical end users
- Exposure to EDI transactions (837, 835)
- Experience with coding tools (3M, Webstrat, Encoder)
- Collaborative mindset and ability to work across cross-functional teams
- Ability to work independently and multi-task
- Proficiency in Outlook, Word, Excel, and related applications
- Goal-oriented with ability to generate multiple data-mining concepts monthly
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