Senior Data Mining & Payment Integrity Lead (Remote)

Gainwell Technologies; Texas; Remote; USD 69,000 - 99,000; Full time

Benefits offered by this job

Educational assistance

Health benefits

401(k) matching

Flexible vacation policy

Leadership and technical academies

Job summary

Gainwell Technologies is seeking a Senior Data Mining & Payment Integrity Analyst. You will design and develop data mining concepts to identify improper payments and improve claims accuracy across dental, medical, and pharmacy billing.

This role requires healthcare reimbursement knowledge and the ability to translate policy into scalable analytics solutions. You will collaborate with cross-functional teams to support client payment integrity strategies, audit processes, and internal reviews,

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 CMS regulations and coding guidelines to healthcare claims data.

Responsibilities

• Develop and implement new data mining opportunities to identify overpayments to providers through data review and analytics across dental, medical, and pharmacy claims.
• Act as a senior member of the team and mentor lower-level analysts.
• 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.
• Ensure individual and departmental goals are consistently met or exceeded through collaboration with other team members and management.
• 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.
• Collaborate with engineers to develop and implement technological improvements that support the audit process.
• Contribute innovative ideas for improving existing audit processes and audit queries.

Skills

Healthcare Payment Integrity

Data Mining

Healthcare Claims Analysis

CMS Guidelines

Job description

Gainwell Technologies is seeking a Senior Data Mining & Payment Integrity Analyst. You will design and develop data mining concepts to identify improper payments and improve claims accuracy across dental, medical, and pharmacy billing.

This role requires healthcare reimbursement knowledge and the ability to translate policy into scalable analytics solutions. You will collaborate with cross-functional teams to support client payment integrity strategies, audit processes, and internal reviews,