Job description
Position Summary:
The Data Mining Senior Auditor is a key audit professional on the data mining review operations team who will identify medical cost savings for healthcare insurance clients through the development of data mining strategies, strategy implementation, and on-going saving strategy enhancements. The role will ensure strategic operational and financial goals are met. The role requires expertise in healthcare claims and claims processing which can lend to the development of cost saving strategies that will favorably impact the insurance organization.
Responsibilities:
- Support Payment Integrity team members with development, implementation and maintenance of operational reports and dashboards.
- Ensure resources are accurate, up-to-date, and can be analyzed to reveal critical insights applicable to strategic initiatives.
- Produce detailed data mining reports for the Payment Integrity pillars.
- Extract critical and pertinent information from the data sets that help the stakeholders understand optimal outcomes.
- Effectively process and integrate primary and/or secondary data sources using database warehouse and visual applications.
- Develop effective quality control processes to ensure data integrity.
- Utilize data analytics to reveal critical business insights and findings.
- Create and deploy PI edits and algorithms to flag suspect claims and drive savings.
- Perform ad-hoc analysis to quantify and prioritize potential savings opportunities.
- Triage PI referrals from local markets, HCE, Clinical Affordability to assess risk.
- Build and provide sustainable audit processes that ensure overpayment findings accuracy.
- Assist with concept development.
- Drive opportunities to standardize process and enhance account management reporting.
- Optimize technology solutions to enhance quality, minimize errors, and expedite issue resolution.
- Work with team leadership to communicate challenges and recommended solutions.
- Work with data mining leadership to communicate operations needs to executive leadership.
Qualifications:
- Seven (7) years of medical claims investigation or data mining, 5 years in a leadership role
- Demonstrated healthcare claims industry expertise.
- Attainment of relevant medical billing and coding certification along with a bachelors’ degree in a relevant field are both highly preferred.
- Minimum high school diploma or GED.
- Problem solving and solutions focused.
- Attention to detail, and commitment to client satisfaction.
- Comfortable interpreting data and developing meaningful insights, analytical mindset.
- Experience with developing measures for performance and quality measurement.
- Strong oral and written communication skills
- Aptitude to quickly learn software platforms such as MS SQL Server, Power BI, and other tools.
- Knowledge of coding type edits and medical claim reimbursement structures and methodologies
- Proficiency with medical terminology, medical procedures, medical conditions, and illness and treatment practices
- Experience in applying principles of coding guidelines; federal/state regulations and policies pertaining to coding and billing.
- Knowledge in researching state and federal healthcare guidelines, e.g., Medicare and State Medicaid Programs
- Familiarity with automated medical claims payment systems and/or working knowledge of payer systems (e.g., Facets, QNXT, etc.)
- Advanced computer skills and proficiency with Microsoft Excel.
- Mature professional with ability to work independently in remote work settings.
Remote Work Requirements
- High speed internet (100 Mbps per person recommended) with secured WIFI.
- A dedicated workspace with minimal interruptions to protect PHI and HIPAA information.
- Must be able to sit and use a computer keyboard for extended periods of time.
Benefits and perks include:
- Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents.
- 401(k) with Employer Match - Join the team and we will invest in your future
- Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays.
- Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered.
- Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional.
Salary Range: $110,000- $115,000/ annually.
