Senior Data Mining & Payment Integrity Analyst

Gainwell Technologies LLC; Ohio; On-site; USD 69,000 - 99,000; Full time

Benefits offered by this job

Flexible vacation policy

Educational assistance

401(k) employer match

Health benefits

Leadership and technical development s

Job summary

Gainwell Technologies LLC is seeking a seasoned healthcare data professional to join our team, focusing on payment integrity and data mining to identify overpayments across dental, medical, and pharmacy claims.

You will review guidelines and contracts, develop algorithms, and support client services with QA, documentation, and stakeholder training. This role offers growth through leadership and technical development academies, competitive benefits, and flexible learning opportunities.

Qualifications

• 5 years of Healthcare Payment Integrity and/or Data Mining experience.
• At least 3 years of Domain Specific experience in Medical, Dental, or Pharmacy claims analysis.
• Experience applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data.

Responsibilities

• Develop data mining to identify provider overpayments across dental, medical, and pharmacy claims.
• Research industry guidelines and client policies to develop improper payment algorithms.
• Review provider contracts to identify algorithms for overpayments.
• Implement payment analytics concepts for new and existing clients.
• Support the appeals, validation, and client services teams in resolving production queries.
• Review IT programming results for quality assurance and proof of concept validation.
• Document query results and prepare internal and external documentation.
• Partner with operations and clinical teams to develop and audit protocols.

Skills

Data mining

Healthcare analytics

Claims analysis

Job description

Be part of a team that unleashes the power of leading‑edge technologies to help improve the health and well‑being of those most vulnerable in our country and communities. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

• Develop and implement new data mining opportunities to identify overpayments to providers through data review and analytics across dental, medical, and pharmacy claims.
• Research industry standard guidelines, State and Federal regulations, and client billing and reimbursement policies to develop and configure improper payment algorithms.
• Review provider contracts to identify algorithms for the identification of contract‑based overpayments.
• Implement current Payment Analytics concepts for new and existing clients while ensuring client policy is supportive and properly applied.
• Support the appeals, validation, and client services teams in resolving outstanding issues related to production queries.
• Review IT programming results for quality assurance and proof of concept validation.
• Document query results and prepare internal and external documentation and presentations related to new overpayment issues.
• Partner with internal operations and clinical teams to develop, implement, review, and audit protocols and internal review guidelines.

• 5 years of Healthcare Payment Integrity and/or Data Mining experience.
• At least 3 years of Domain Specific experience in Medical, Dental, or Pharmacy claims analysis .
• Experience in Healthcare Auditing, including Reviewing and Validating the Accuracy of Claims Data and the Accuracy of Claims Payment , is preferred.
• Experience Applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data . Opportunities to travel through your work (0-10%)
• Video cameras must be used during all interviews, as well as during the initial week of orientation

The pay range for this position is $69,400.00 - $99,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job‑related knowledge, skills, and experience among other factors. All salaried, full‑time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.