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