Job Description
Position Summary: As a Data Mining Ideation Specialist, you will leverage your deep expertise in medical coding requirements, claims adjudication processes, and reimbursements methodologies to design and develop data mining audits that drive payment accuracy across our clients Medicaid, Medicare, and Commercial lines of business. This role is ideal for someone who thrives at the intersection of coding, analytics, and audit development. Someone who can translate complex reimbursement policies into actionable audit concepts that identify improper payments with a high degree of precision and consistency.
You will apply strong analytical thinking, an in-depth understanding of claims data, and meticulous attention to detail to uncover overpayment opportunities and build scalable audit logic. In close partnership with audit, analytics, and operations teams, you will define data selection parameters, validate outcomes, and continuously refine audit strategies to improve accuracy and impact. This role also plays a key part in supporting production audit teams through training, guidance, and ongoing quality initiatives.
This is a remote role. Salary Range 80-100K depending upon experience. Primary Responsibilities: - Leverage Federal, State, Local, and Client-specific contracts, rules, regulations, and policies to identify data mining audit opportunities.
- Define data selection requirements and validate output to ensure accurate selections.
- Become a data SME for designated Client(s).
- Assist with obtaining Client approvals and any ad-hoc Client requests.
- Develop concept-specific training materials for audit staff.
- Monitor audit performance to ensure ongoing accuracy and to assess potential logic revisions.
- Maintain expertise on CPT, HCPCS, and ICD-10 Coding guidelines, other claim submission requirements, and reimbursement methodologies.
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 Certified Professional Coder (CPC), Certified Outpatient Coder (COC) certification, or
- Certified Coding Specialist (CCS) certification through AHIMA or
- RHIT designation
- Expert level understanding of medical claim coding and its impact on claim payments, including in-depth understanding of various reimbursement methodologies and the direct impact of incorrect coding.
- Ability to develop data mining audits, apply regulatory standards, and contractual requirements with credibility and objectivity.
- Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures and documentation.
- Knowledge of health insurance operations, specifically with claims processing, billing, reimbursement, or provider contracting.
- Prior experience in payer edit development, and/or reimbursement policy experience. For example:
- CMS policies and practices, including NCD’s and LCD’s, NCCI Edits for PTP and MUE, and DRG, APC, EAPG groupers
- Multiple Surgery Reductions
- 3-Day Payment Window
- Eligibility and COB
- Expertise in data analysis and EXCEL.
- Strong analytical and problem-solving abilities.
- Effective communication skills.
- Meticulous attention to detail.
Desirable Qualifications: - Python or SQL coding skills.
- Clinical background or experience.
- Demonstrated experience translating technical jargon to non-technical end users.
- Previous experience in the Payment Integrity space.
- Exposure to EDI transactions (837, 835).
- Experience using coding tools (such as 3M, Webstrat, and Encoder)
- Collaborative mindset and ability to work effectively across cross- functional teams.
- Proficiency in Outlook, Word, Excel, and other applications.
- Ability to work independently and can multi-task or transition to different tasks easily.
What Success Looks Like:
- Develop and deliver 6+ new audit concepts monthly, including logic specifications aligned with reimbursement policies
- Submit 4+ high-impact audit concepts per month, contributing to a minimum of $975K in identified overpayment opportunities
- Partner with internal teams to move concepts from ideation to client review and production implementation
- Ensure timely communication and follow-through:
- Respond to inquiries within 1 business day
- Complete research and provide updates within 3 business days
- Drive resolution, including logic revisions or claim actions, within 5 business days
- Monitor audit performance, including yield and appeal outcomes, and continuously refine logic for accuracy and impact
- Collaborate with Operations and Management to support audit effectiveness and quality initiatives
- Complete "Second Look" reviews within established turnaround times
Job Tags
Full time, Local area, Remote work