Data Mining Sr. Analyst

Machinify; United States; Remoto; USD 125.000 - 135.000; Tempo pieno

Vantaggi offerti da questo lavoro

Remote work (US)

Medical/Dental/Vision benefits

401(k) with company match

FSA/HSA

Descrizione del lavoro

Machinify, a leading healthcare intelligence company, seeks a Senior Analyst to lead the development and refinement of reimbursement and payment integrity concepts. This hands-on role focuses on claims data, contract terms, and payer rules to shape analytics and automation strategies.

You'll partner with engineering and data science teams to translate policy and contract knowledge into actionable logic, identify overpayments, and ensure accurate payments across CMS and commercial payers.

Competenze

• 5+ years of experience in healthcare data mining or claims editing.
• Deep understanding of provider contracts and reimbursement methodologies.
• Strong knowledge of CMS and commercial payer rules.
• Ability to identify improper payment patterns and root causes.
• Strong investigative and deductive reasoning skills.
• Comfortable guiding implementation with technical teams.
• Self-directed and detail-oriented in a fast-paced environment.

Mansioni

• Lead pre and post-pay claim reviews to identify inaccurate payments.
• Analyze provider contracts to ensure payments align with negotiated terms and payer rules.
• Collaborate with engineering and data science to translate logic into analytical/automation frameworks.
• Research and document emerging reimbursement patterns and billing practices to inform concept development.
• Translate complex reimbursement scenarios into structured rules for implementation.
• Analyze claim-level data to pinpoint root causes of overpayments or incorrect denials and propose corrections.
• Maintain expertise on CMS and commercial payer reimbursement guidelines.
• Support quality review, concept validation, and process improvement initiatives.

Conoscenze

Healthcare data mining

Claims editing

Contract interpretation

Problem solving

Analytical thinking

Cross-functional collaboration

Deductive reasoning

Formazione

CPC/CCS certification

Strumenti

SQL

Descrizione del lavoro

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Machinify is seeking a Senior Analyst to lead the development and refinement of new reimbursement and payment integrity concepts. This is a hands‑on healthcare domain role, not a technical or engineering position. The ideal candidate understands reimbursement logic, payment policies, and provider contracts in depth — and can translate that expertise into clear, structured concepts that inform analytics and automation efforts.

You will be focused on discovering where and why payment errors occur, designing methods to detect and prevent them, and partnering with technical teams to operationalize your findings. This role is ideal for someone who loves digging into claims data, identifying systemic payment issues, and shaping how technology solutions capture real-world reimbursement logic.

What You’ll Do

• Lead pre and post‑pay claim reviews to identify inaccurate payments using reimbursement and contract expertise.
• Analyze and interpret provider contracts to ensure payments align with negotiated terms, methodologies, and payer rules.
• Collaborate closely with engineering and data science teams to translate business and reimbursement logic into analytical and automation frameworks.
• Research and document emerging reimbursement and contract patterns, coverage rules, and billing practices to inform concept development.
• Translate complex reimbursement and contract scenarios into structured rules and business logic for implementation.
• Analyze claim‑level data to pinpoint root causes of overpayments or incorrect denials and recommend corrective approaches.
• Maintain expertise on CMS and commercial payer reimbursement guidelines.
• Support quality review, concept validation, and process improvement initiatives.

What You Bring

• 5+ years of experience in healthcare data mining or claims editing on the provider, payer, or vendor side.
• Deep understanding of provider contracts, including rate structures, carve‑outs, and reimbursement methodologies.
• Strong knowledge of claims processing, coding, billing, and payment logic across CMS and commercial payers.
• Proven ability to identify improper payment patterns, root causes, and opportunities for correction.
• Strong investigative and deductive reasoning skills; able to connect policy, data, and contractual details.
• Comfortable working in close collaboration with technical teams to guide implementation of business logic.
• Self‑directed, detail‑oriented, and adaptable to a fast‑paced, growing environment.

Preferred Qualifications

• Coding certification (e.g., CPC, CCS, or equivalent).
• Working proficiency in SQL for data exploration and validation.
• Prior experience in cross‑functional R&D or innovation teams focused on healthcare payment integrity.

What We Offer

• Work from anywhere in the US! Machinify is digital‑first.

Top Medical/Dental/Vision offerings

FSA/HSA

Competitive salary, 401(k) with company match

Additional health and wellness benefits and perks

• Flexible and trusting environment where you’ll feel empowered to do your best work

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc.

Pay range: $125,000 - $135,000

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E‑Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know.

See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/