Senior Data Mining, Payment Integrity Analyst

🕒 Abril 13

🤠 Texas – Remoto

🤠 Texas – Remote

💵 $69.400 - $99.200 / ano

⏰ Tempo Integral

🟠 Sênior

🧐 Analista

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Gainwell Technologies

SiteLinkedInTodas as Vagas

10.000+ funcionários

⚕️ Seguro de Saúde

💰 Grant em 2023-06

Healthcare Insurance • Human Services • Healthcare

A Gainwell Technologies é a principal provedora do país de soluções digitais e cloud-enabled em todo o ecossistema de serviços humanos e saúde pública. Com uma abordagem orientada por propósito, a Gainwell atende clientes nos 50 estados dos EUA, com foco em melhorar os desfechos em saúde e oferecer experiências intuitivas e centradas nas pessoas. Seu portfólio abrangente inclui modernização do Medicaid Enterprise, data analytics, serviços para prestadores e soluções para farmácia — tudo projetado para impulsionar o futuro da saúde e promover o bem-estar das comunidades.

Descrição

• 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

🎯 Requisitos

• 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

🏖️ Benefícios

• generous, flexible vacation policy • educational assistance • comprehensive health benefits • 401(k) employer match • comprehensive leadership and technical development academies