Consultant II Data Mining

A Payment Integrity Data Mining Consultant II, is a professional who is market/ client facing and responsible for identifying new audit opportunities, researching new pricing methodologies, and engaging with various work teams to generate systems automation and enhancement capabilities in our state-of-the-art audit workstation. Data Mining Lead is an IC role which identifies, develops, and implements new concepts that recognize incorrect payments. These concepts are developed based on industry experience, regulatory research, and the ability to analyze medical claim data to discover incorrect payments. This role is responsible for analyzing client data and generating high quality recoverable claims, assisting in the identification, validation, and documentation of moderate to more complex recovery projects.Consultant II Data Mining

Education:

High School Diploma or equivalent required. BA/BS in Business Administration or related field or equivalent preferred but not necessary

Experience:

5+ year’s knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required 

Mandatory Skills:

• Experience in Ideating & developing new auditing rules and paradigms.

• Experience in Business case analysis and help designing BRD.

• Experience in Pricing, COB, platform analytics.

• Experience of Validation of Rules through testing methodologies.

• Experience in auditing, payment processing, or financial fraud prevention is a must.

• Load and synthesize healthcare data from multiple sources.

• Experience working within a health plan, managed care organization, provider operated healthcare environment or third party administrator.

• Development of end to end payment Integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical record Management, Audit Operations, Recovery Operations, Provider Correspondence and Forecasting & Invoicing.

• Maintaining working knowledge of CMS transmittals, RAC, and OIG reports is a must.

• Prior claims auditing or consulting experience desirable in either a provider or payer environment.

• Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings.

• Work with audit teams and establish a process to ensure the concepts being deployed are working as expected with higher findings thus ensuring higher hit rates and findings rates on the concepts deployed.

• Excellent communication skills both oral and written.

• Strong interpersonal skills that will support collaborative teamwork.

• Microsoft Office Proficient: Word and Excel; Access – highly preferred

• Ability to interpret and assess complex payment datasets.

• Excellent communication and interpersonal skills.

Preferred Skills:

• Knowledge of payment systems, financial transactions, and claims processes end to end.

• Understanding of payment integrity concepts and fraud detection methodologies.

• Experience in auditing, payment processing, or financial fraud prevention is a plus.• Experience working within a health plan, managed care organization, provider operated healthcare environment or third party administrator.

• Development of end to end payment Integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical record Management, Audit Operations, Recovery Operations, Provider Correspondence and Forecasting & Invoicing. 

 

Roles & Responsibilities:

The Key responsibility for the role is market/ client facing. This role will be reviewing and analysing payment-related data using data mining techniques to ensure accuracy, compliance, and fraud prevention in financial transactions. Their primary objective is to ideate and perform audits on payment data, identify discrepancies, errors, and fraudulent activities, and provide recommendations for process improvement. This position is responsible for data collection, data analytics and data reporting for Data Mining programs including but not limited to COB, Duplicate, Contractual, billing errors, overlapping services etc. This position has to Influence leadership to adopt new ideas, and products as an experienced industry leader and provide executive level program updates and manage team escalations and operate as an industry thought leader in Payment Integrity.

The above statements are intended to indicate the general nature and level of work being performed by employees within this classification. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of employees assigned to this job. Employees in this job may perform other duties as assigned. 

Work@Home USAUnited States of America