Senior Data Mining, Payment Integrity Analyst

🕒 April 13

🤠 Texas – Remote

🤠 Texas – Remote

💵 $69.4k - $99.2k / year

⏰ Full Time

🟠 Senior

🧐 Analyst

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

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