Data Mining Senior Auditor

We are seeking a Data Mining Senior Auditor to join our Payment Integrity team. This role is responsible for identifying healthcare cost-savings opportunities through advanced data mining strategies, claims analysis, audit development, and payment integrity initiatives. The Data Mining Senior Auditor will leverage extensive healthcare claims expertise to uncover overpayments, develop innovative audit concepts, enhance existing savings strategies, and support operational and financial objectives for health plan clients., Data Mining and Audit Strategy

• Develop, implement, and maintain data mining strategies that 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 opportunities for enhanced savings initiatives.
• Assist in the development of new audit concepts and payment integrity programs.
• Continuously evaluate and enhance existing savings strategies to improve client outcomes.

Data Analysis and Reporting

• Produce detailed data mining reports and analyses for Payment Integrity operations.
• Extract and interpret critical information from large healthcare claims datasets to support business and operational decisions.
• Develop and maintain operational reports, dashboards, and performance metrics.
• Utilize data analytics tools to identify meaningful business insights and opportunities.
• Perform ad hoc analyses to quantify, prioritize, and validate savings opportunities.

Operational Excellence and Quality

• Develop and maintain quality control processes to ensure data accuracy, consistency, and integrity.
• Build sustainable audit processes that ensure overpayment findings are accurate, defensible, and repeatable.
• Optimize technology solutions and workflows to improve efficiency, reduce errors, and support issue resolution.
• Identify opportunities to standardize processes and improve operational reporting capabilities.
• Support ongoing process improvement initiatives across the Payment Integrity function., * Collaborate with Payment Integrity, Clinical, Operations, and Analytics teams to support organizational objectives.
• 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.

This position requires strong analytical skills, deep knowledge of healthcare claims processing and reimbursement methodologies, and the ability to transform complex data into actionable insights that drive measurable client savings., * 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.
• Demonstrated 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., * Bachelor’s degree in Health Information Management, Healthcare Administration, Data Analytics, Business, or a related field.
• CPC, CCS, CPMA, RHIA, RHIT, or other relevant coding, billing, or auditing certification.
• Experience with SQL, data warehousing, Power BI, and advanced healthcare analytics tools.
• Experience developing healthcare payment integrity concepts resulting in measurable client savings.
• Experience working with health plans, third-party administrators, or payment integrity organizations., * 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.

$85,000 - $90,000 annually, commensurate with experience.

MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third-party administrators, and other healthcare organizations to deliver technology-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes.