Data Mining Strategist for Payment Integrity & Auditing

MedReview Inc.; United States; On-site; USD 90,000 - 110,000; Full time

Job summary

MedReview is seeking a Data Mining Ideation Specialist to develop audit concepts that improve payment accuracy across Medicaid, Medicare, and Commercial lines. You will leverage deep CPT/HCPCS/ICD coding knowledge and claims adjudication experience to identify improper payments with high accuracy.

The role requires advanced Excel and data analysis skills, strong communication, and the ability to manage multiple priorities in a fast-paced environment.

Qualifications

• Five years or more of complex claims processing, auditing, or payment integrity experience.
• Masters of CPT/HCPCS/ICD coding standards knowledge.
• Current coding certification: CPC/COC/CCS/RHIT.
• Strong Excel and data analysis skills.
• Excellent written and verbal communication.
• Ability to manage multiple priorities in a fast-paced environment.

Responsibilities

• Identify and develop data mining audit concepts to promote payment accuracy across Medicaid, Medicare, and Commercial lines.
• Define data selection criteria and audit logic to ensure accurate claim identification.
• Validate audit outputs for integrity and consistency across audits.
• Serve as subject matter expert for designated clients and audit concepts.
• Assist with client approvals and responses related to audit concept development and performance.
• Develop training materials for audit staff and operations teams.
• Monitor audit performance and identify opportunities for improvements and logic revisions.
• Collaborate with analytics, operations, audit, and client services teams on payment integrity opportunities.
• Research regulatory changes impacting audit development.
• Support quality assurance initiatives and provide guidance on audit accuracy.

Job description

MedReview is seeking a Data Mining Ideation Specialist to develop audit concepts that improve payment accuracy across Medicaid, Medicare, and Commercial lines. You will leverage deep CPT/HCPCS/ICD coding knowledge and claims adjudication experience to identify improper payments with high accuracy.

The role requires advanced Excel and data analysis skills, strong communication, and the ability to manage multiple priorities in a fast-paced environment.