Data Mining Ideation Specialist

🔥 8 minutes ago

🇺🇸 United States – Remote

💵 $90k - $110k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 2%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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MedReview Inc.

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

⚕️ Healthcare Insurance

💸 Finance

Healthcare • Healthcare Insurance • Finance

MedReview Inc. is a leading provider of advanced payment integrity solutions, specializing in healthcare claims. They work with a wide range of clients, including health plans, government agencies, and payors, to reduce unnecessary waste and save billions of dollars. Their team of highly trained physicians, registered nurses, and certified coders conduct thorough clinical and coding reviews to identify inaccuracies in healthcare claims. MedReview employs proprietary algorithms to analyze complex data and detect suspicious payment trends, offering a unique blend of clinical expertise and advanced technology to maximize efficiencies and improve healthcare cost management.

📋 Description

• Identify new data mining audit opportunities using Federal, State, local, and client-specific regulations, contracts, policies, and reimbursement guidelines • Develop data selection criteria and audit logic requirements for accurate claim identification • Validate audit outputs and results for integrity, consistency, and payment accuracy • Serve as a subject matter expert for designated clients and audit concepts • Assist with client approvals and respond to client requests related to audit concept development and performance • Develop and maintain concept-specific training materials for audit staff and operational teams • Monitor audit performance and identify opportunities for improvements, enhancements, and logic revisions • Maintain expertise in CPT, HCPCS, and ICD-10 coding guidelines, reimbursement methodologies, and claim submission requirements • Collaborate with analytics, operations, audit, and client services teams to identify and implement payment integrity opportunities • Research emerging healthcare regulations, coding updates, and reimbursement policy changes affecting audit development • Support quality assurance initiatives and guide audit accuracy and concept implementation • Perform additional projects and duties as assigned

🎯 Requirements

• Minimum of five (5) years of complex claims processing, claims auditing, medical coding, or payment integrity experience within the healthcare industry • Knowledge of Medicare, Medicaid, and Commercial health insurance plans and reimbursement methodologies • Prior experience developing payment integrity, data mining, or reimbursement audit concepts strongly preferred • Mastery of CPT, HCPCS, and ICD coding standards and guidelines • Current coding certification required: AAPC Certified Professional Coder (CPC), AAPC Certified Outpatient Coder (COC), AHIMA Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT) • Expert understanding of medical claim coding and its impact on claim reimbursement and payment accuracy • Strong knowledge of healthcare claim processing, billing regulations, reimbursement methodologies, and provider contracting principles • Knowledge of legal, regulatory, compliance, and documentation requirements related to medical coding and billing practices • Experience interpreting NCDs, LCDs, NCCI PTP Edits, MUEs, DRG/APC/EAPG methodologies, Multiple Surgery Reductions, Three-Day Payment Window regulations, and Eligibility/COB requirements • Advanced proficiency in Microsoft Excel and data analysis techniques • Strong analytical, organizational, and problem-solving skills • Excellent verbal, written, and interpersonal communication skills • Exceptional attention to detail and commitment to quality • Ability to manage multiple priorities in a fast-paced environment • Experience with Python, SQL, or other data analysis and reporting tools preferred • Clinical healthcare experience or background preferred • Experience translating complex technical concepts into user-friendly training materials and documentation preferred • Previous Payment Integrity industry experience preferred • Knowledge of EDI transactions, including 837 and 835 claim formats, preferred • Experience using 3M, WebStrat, Encoder, or similar coding and audit tools preferred • Proficiency with Microsoft Outlook, Word, Excel, and related business applications preferred • Ability to work independently while managing multiple projects and changing priorities preferred • Legally authorized to work in the United States without current or future employment-based immigration sponsorship

🏖️ Benefits

• Medical, Dental, and Vision Insurance • 401(k) Retirement Plan • Life and Disability Insurance • Paid Time Off and Company Holidays • Flexible Spending Accounts (FSA) • Employee Assistance Program (EAP) • Competitive compensation • Collaborative environment supporting professional growth, innovation, and continuous improvement

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