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

📌 Manager– Data Mining (Hyderabad)
🏢 EXL
📍 Hyderabad