[Hiring] Senior Data Mining & Payment Integrity Analyst @Gainwell Technologies LLC

Role Description

As a Senior Data Mining & Payment Integrity Analyst , you will design and develop data mining concepts that identify improper payments and improve claims accuracy across dental, medical, and pharmacy billing. Using your expertise in healthcare reimbursement, regulations, and data analysis, you will translate complex policies into scalable audit and analytics solutions. You will collaborate with cross-functional teams to drive innovation, support client payment integrity strategies, and help safeguard healthcare resources for the populations our clients serve.

• 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.

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 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. Recovery audit experience is preferred.

Requirements

• 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.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.

Company Description

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.