Quality Analyst – Data Mining, Payment Integrity

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EXL

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

📦 Logistics

💰 $2M Venture Round on 2015-01

Healthcare • Insurance • Logistics

EXL is a business consulting and services firm that focuses on leveraging data to enhance business operations and decision-making. With a strong emphasis on collaboration and adaptability, EXL partners with organizations to address their unique needs and culture while integrating data science and technology solutions. The company's areas of expertise include operations management, decision analytics, digital transformation, and various industries such as healthcare, finance, and insurance. EXL's mission is to help clients drive business evolution and maintain competitive advantage through tailored solutions and effective use of data.

📋 Description

• Perform quality control reviews of completed Data Mining audit findings to validate claim accuracy, payment methodology, recovery opportunity, and compliance with client-specific requirements • Review provider contracts, fee schedules, client claim systems, pricing references, coding guidelines, and audit notes to confirm findings are supported and documented • Validate complex claim repricing using client claims systems, pricing tools, CMS guidelines, coding resources, and program procedures • Monitor, analyze, and report error trends, root causes, pass/fail outcomes, and recurring issues affecting payment accuracy, audit quality, and operational performance • Recommend corrective actions, training opportunities, and quality improvement initiatives • Evaluate audit processes, controls, procedures, and Data Mining concepts; review query-driven audit outputs for effectiveness, consistency, efficiency, compliance, and recovery alignment • Partner with audit leadership, trainers, and subject matter experts on requirements clarification, process improvements, calibration, quality initiatives, procedure updates, and special projects • Ensure audit work complies with client, program, regulatory, HIPAA, and company requirements while maintaining confidentiality

🎯 Requirements

• High School Diploma required • Minimum 5+ years of experience in medical claims, healthcare auditing, Payment Integrity, coding, claim quality review, or related healthcare operations • Strong understanding of complex medical claim processing, provider payment methodologies, claim systems, and audit documentation requirements • Ability to interpret client requirements, provider contracts, fee schedules, coding guidelines, pricing rules, and healthcare compliance standards • Strong verbal and written communication skills with the ability to provide clear, professional, and actionable feedback • Ability to work independently, manage multiple priorities, meet deadlines, and maintain accuracy in a production-based environment • Extensive knowledge of medical claims processing, healthcare reimbursement methodologies, provider payment logic, and overpayment recovery concepts • Strong understanding of CMS pricing and reimbursement guidelines, provider contract interpretation, fee schedules, and claim payment methodologies • Knowledge of CPT, HCPCS, ICD-10-CM, and medical coding methodologies; ICD-9 knowledge helpful where applicable • Proficiency with Microsoft Excel, PowerPoint, Outlook, Word, spreadsheets, databases, and data analysis tools • Ability to review query-driven audit outputs and understand Data Mining logic for claim selection, overpayment identification, audit validation, and quality outcomes • Exceptional analytical and critical-thinking skills to identify patterns, root causes, quality trends, process improvement opportunities, and corrective actions • Commitment to accuracy, quality, attention to detail, confidentiality, and compliance with client, company, and healthcare requirements • Experience analyzing complex healthcare claims, large healthcare claims datasets, and payment trend information • Strong understanding of quality assurance principles, audit accuracy standards, QC criteria, error prevention, and quality review guidelines • Effective written and verbal communication skills and ability to provide constructive feedback and collaborate with auditors, leaders, trainers, and client-facing teams • College degree preferred • CPC or other nationally recognized coding certification preferred; relevant experience may be considered in lieu of certification • Payment Integrity, healthcare reimbursement, or overpayment recovery audit experience preferred • Prior quality review, claim audit, or audit validation experience strongly preferred • Experience applying quality criteria, audit scorecards, accuracy standards, or structured quality review guidelines • Experience with healthcare claim systems and tools such as FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat/Webtrat, and applicable pricers

🏖️ Benefits

• Up to 10% annual travel for team meetings and limited client onsite engagements • Opportunity to work closely with experienced Healthcare consultants • Exposure to multiple aspects of clients’ businesses • Mentoring program with guidance/coaching and a senior-level professional advisor for every junior-level employee • Teamwork and time-management development • Growth and development opportunities