Note: The job is a remote job and is open to candidates in USA. Gainwell Technologies is a company dedicated to improving the health and well-being of vulnerable populations through innovative technology. As a Senior Data Mining & Payment Integrity Analyst, you will design and develop data mining concepts to identify improper payments and enhance claims accuracy in healthcare. This role involves collaborating with cross-functional teams to support client payment integrity strategies and ensuring compliance with healthcare regulations.
Responsibilities
- Develop and implement new data mining opportunities to identify overpayments to providers through data review and analytics across dental, medical, and pharmacy claims
- Act as a senior member of the team and mentor lower-level analysts
- Research industry standard guidelines, State and Federal regulations, and client billing and reimbursement policies to develop and configure improper payment algorithms
- Review provider contracts to identify algorithms for the identification of contract-based overpayments
- Implement current Payment Analytics concepts for new and existing clients while ensuring client policy is supportive and properly applied
- Support the appeals, validation, and client services teams in resolving outstanding issues related to production queries
- Ensure individual and departmental goals are consistently met or exceeded through collaboration with other team members and management
- Review IT programming results for quality assurance and proof of concept validation
- Document query results and prepare internal and external documentation and presentations related to new overpayment issues
- Partner with internal operations and clinical teams to develop, implement, review, and audit protocols and internal review guidelines
- Collaborate with engineers to develop and implement technological improvements that support the audit process
- Contribute innovative ideas for improving existing audit processes and audit queries
Skills
- 5 years of Healthcare Payment Integrity and/or Data Mining experience
- At least 3 years of Domain Specific experience in Medical, Dental, or Pharmacy claims analysis
- Experience in Healthcare Auditing, including Reviewing and Validating the Accuracy of Claims Data and the Accuracy of Claims Payment
- Experience Applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data
- Recovery audit experience
Benefits
- Generous, flexible vacation policy
- Educational assistance
- Comprehensive health benefits
- 401(k) employer match
- A variety of leadership and technical development academies to help build your skills and capabilities
Company Overview
Company H1B Sponsorship