Senior Data Mining & Payment Integrity Analyst

Summary

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

Role in Our Mission

• 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.

What We Are Looking For

• 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, is preferred.
• Experience Applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data. Recovery audit experience is preferred.

The Role

• Opportunities to travel through your work (0-10%)
• Video cameras must be used during all interviews, as well as during the initial week of orientation

Pay Range

The pay range for this position is $69,400.00 - $99,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.