Payment Integrity Data Mining Ideation SME

As a DATA MINING IDEATION SPECIALIST, you will leverage your expertise in medical coding requirements, claim adjudication processes, and reimbursement methodologies to develop Data Mining audits that promote payment accuracy across our Clients’ Medicaid, Medicare, and Commercial lines of business. Your strong analytical skills, in-depth understanding of claims data, and attention to detail are key to success in creating audit concepts that identify improper payments with the highest possible degree of accuracy and consistency. The SPECIALST collaborates with audit, analytics, and operations teams to identify new overpayment opportunities, define data selection parameters, and validate results. The SPECIALIST also provides training for production audit staff, and ongoing support for education and 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. Goals and Expectations: The SPECIALIST is expected to generate logic specification requirements for a minimum of SIX new Concepts each month, with a minimum of FOUR moving forward. The SPECIALIST will acknowledge all inquiries within one business day. When further research is required, it will be completed and the inquirer updated, within the next two business days. (total of 3 business days) When additional action, including revising logic or closing claims, is required, it must be initiated, and the inquirer updated as to status, within the next two business days. (total of 5 business days) The SPECIALIST monitors the updates and ensures full and final resolutions, striving for completion within seven total business days. The SPECIALIST, in conjunction with Management and Operations staff, monitors Concept performance including yield and appeal statistics. The SPECIALIST completes “Second Look” requests within two business days.