Senior Data Mining Auditor

🔥 8 minutes ago

🇺🇸 United States – Remote

💵 $85k - $90k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

👻 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

• Develop, implement, and maintain data mining strategies to identify claims overpayments and cost-saving opportunities • Create and deploy payment integrity edits, algorithms, and auditing methodologies to flag suspect claims and drive recoveries • Perform detailed claims analyses to identify trends, patterns, and enhanced savings opportunities • Assist in developing new audit concepts and payment integrity programs • Evaluate and enhance existing savings strategies to improve client outcomes • Produce detailed data mining reports and analyses for Payment Integrity operations • Extract and interpret information from large healthcare claims datasets • Develop and maintain operational reports, dashboards, and performance metrics • Use data analytics tools to identify business insights and opportunities • Perform ad hoc analyses to quantify, prioritize, and validate savings opportunities • Develop and maintain quality control processes for data accuracy, consistency, and integrity • Build sustainable audit processes ensuring overpayment findings are accurate, defensible, and repeatable • Optimize technology solutions and workflows to improve efficiency, reduce errors, and support issue resolution • Standardize processes and improve operational reporting capabilities • Support process improvement initiatives across the Payment Integrity function • Collaborate with Payment Integrity, Clinical, Operations, and Analytics teams • Assess and triage referrals from health plans, Clinical Affordability teams, healthcare economics departments, and other stakeholders • Communicate operational challenges, findings, and recommendations to leadership • Partner with Data Mining leadership to communicate operational needs and strategic opportunities to executive leadership • Support cross-functional initiatives that improve audit performance and maximize client savings

🎯 Requirements

• Minimum high school diploma or GED required • Seven (7) or more years of healthcare claims investigation, payment integrity, or data mining experience • Five (5) or more years of leadership experience within healthcare auditing, payment integrity, or related functions • Expertise in healthcare claims processing, reimbursement methodologies, and payment integrity concepts • Strong analytical, critical thinking, and problem-solving skills • Experience developing performance measures and quality assurance methodologies • Strong verbal and written communication skills • High attention to detail and commitment to client satisfaction • Advanced proficiency with Microsoft Excel • Ability to quickly learn and utilize SQL Server, Power BI, and related analytics platforms • Knowledge of coding edits, reimbursement methodologies, and medical claims payment systems • Understanding of medical terminology, procedures, diagnoses, treatment practices, and claims adjudication processes • Experience applying coding guidelines, billing regulations, and federal and state healthcare policies • Knowledge of Medicare, Medicaid, and commercial payer reimbursement requirements • Experience working with healthcare payer systems such as Facets, QNXT, or similar claims platforms • Ability to work independently in a remote environment • High-speed internet connection (100 Mbps recommended) • Dedicated workspace with minimal interruptions and the ability to protect PHI and HIPAA-sensitive information • Ability to work at a computer and utilize a keyboard for extended periods • Ability to work legally in the United States without current or future employer sponsorship

🏖️ Benefits

• Remote work arrangement • High-speed internet connection requirement (100 Mbps recommended) • Dedicated workspace with minimal interruptions • Ability to protect PHI and HIPAA-sensitive information

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