Data Mining Specialist (Payment Integrity)

The Data Mining Specialist role will require a high level of expertise in identifying, developing, and implementing effective data mining queries. This individual must have extensive knowledge across multiple lines of business, including Medicare, Medicaid, and Commercial claims, as well as experience navigating multiple claims payment systems. The role also requires the ability to analyze complex claims, identify payment anomalies and new recovery opportunities, and translate findings into accurate, actionable data mining concepts. These capabilities are critical to maintaining a strong pipeline of opportunities and adapting concepts and query logic across different client environments. 

*Base Pay Range: $93,900 - $134,100/yr

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits

• Access client claim systems to validate claim reimbursement terms as needed 
• Routinely review client contract systems or files for contractual reimbursement terms 
• Create overpayment rules for data mining
• Analyze payer data and identify anomalies or aberrant billing practices
• Perform an extensive review of client accounts to determine if correct payments were made to providers
• Accurately reprice complex claims utilizing multiple client claims systems to perform the tasks
• Identify work files to be audited through a query process
• Documentation of audit findings to be shared with client
• Serve as a resource for junior auditors and new employees
• Identify and develop/validate new overpayment opportunities and recovery concepts
• Serve as a client and program specific SME when called upon in both internal and external settings
• Evaluate current procedures for efficiency and accuracy as well as recommend solutions for process improvements
• Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security and Regulatory policies, procedures, and programs.

Required:

• Minimum of 5 years employment within Payment Integrity Services

• Minimum 5-8 years or equivalent work experience in healthcare/payment integrity/managed care contracts 
• Experience with Medicare, Medicaid, and Commercial claims data
• Experience with industry systems (FACETS, NASCO, Encoder Pro, TrueCode,3M, Webstrat, Pricers)
• Sound knowledge of ICD-10, CPT, and HCPC coding guidelines
• Experience with processing complex medical health claims
• Knowledge of CMS Pricing Guidelines and Coding Methodologies
• Attention to detail and ability to problem solve 
• Excellent computer skills, proficient in excel, word, and outlook 
• Excellent interpersonal skills, and communication skills 
• Able to train and delegate 
• Demonstrate ability to prioritize tasks 
• Excellent organizational skills 

Education: 

• Bachelor’s degree or equivalent work experience in Payment Integrity services 

*The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.