Extensive experience across Medicare, Medicaid or commercial business
- Demonstrated expertise in 360-degree claims review, auditing, and payment integrity
- Proven ability to identify patterns, anomalies, and inappropriate payments within large claims datasets
- Strong analytical mindset with the ability to bridge operations and data science
- Experience collaborating with cross-functional teams (analytics, product, strategy, compliance)
- Excellent communication skills with the ability to explain complex claims concepts clearly
- Prior involvement in payment integrity data mining or recovery initiatives
- Experience supporting or designing claims analytics or data mining non-clinical programs
Responsibilities
Key Responsibilities
- Lead exploratory analysis of claims paid data to identify utilization patterns, anomalies, and potential overpaid or inappropriate claims
- Apply deep knowledge of CMS rules, contract interpretation, reimbursement, and workflows to guide data mining and investigative efforts
- Perform reverse engineering of claims outcomes to understand root causes of payment issues and system behaviors
- Translate operational and claims insights into clear use cases, concepts, and solution ideas for analytics and product teams
- Partner closely with analytics, product, and strategy teams to ensure solutions align with real-world claims operations
- Validate data-driven findings against practical claims and payment realities
- Clearly communicate insights, risks, and opportunities to both technical and non-technical stakeholders
- Support ongoing refinement and scaling of claims monitoring and overpayment detection capabilities
Qualifications
Required Qualifications
- 7+ years of experience in US healthcare claims with a robust focus on claims adjudication and Data Mining payment Integrity