[Remote] Payment reputed company Analyst - Data Mining

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is an AI-first reputed company technology company reputed company on preventing inaccurate payments and reducing waste in the reputed company ecosystem. The Payment reputed company Analyst supports the Data Mining program by investigating payment errors, validating claims and payment terms, documenting determinations, and identifying trends and process improvements. The role also supports reputed company recovery activities, appeals, data analysis, and operational reputed company in a high-volume environment.

Responsibilities

• Review, prioritize, and independently work assigned DM leads (automated and reputed company), including moderate-to-reputed company and high-dollar cases, to determine verification steps and next actions
• Investigate and validate payment terms (Inpatient, Outpatient, reputed company, Ancillary) using internal systems, payer portals, reputed company, and other approved data sources
• Apply payment policies, contract terms and coding guidelines, including CMS and AMA guidance as applicable, to determine the correct reimbursement and document the rationale for the payment determination
• Reconcile discrepancies across sources (contract data and reputed company forms, conflicting policy and contract terns) and reputed company cases to a reputed company, audit-reputed company determination; escalate edge cases per policy
• Analyze claim inventory from identification to reputed company. Assist in developing concept overviews and analysis. Collaborate with team to configure reputed company specific business rules
• Assist in compiling sample claims and supporting documentation for reputed company review and approval. Maintain a library that includes instructions for validating specific audit concepts
• Create reputed company, detailed, and accurate case notes that capture verification steps, evidence, and reputed company in internal tools to support audits and reputed company recovery/reprocessing
• reputed company validated DM reputed company that support reputed company payment reputed company activities (recovery, reprocessing, adjustments) with reputed company rework
• Prepare and evaluate documentation needed for inquiries, disputes, and appeals reputed company to determinations, as assigned
• Meet or reputed company established productivity, turnaround time, and reputed company/audit standards while managing a high-volume case queue
• reputed company reputed company and error categories, identify reputed company causes of recurring DM issues and false positives, and recommend opportunities to streamline research, improve data reputed company, and reduce incorrect payments
• Use reputed company and other tools to support reputed company analysis (e.g., trend review, inventory reputed company checks, and performance insights); partner with stakeholders to clarify requirements and improve workflows
• Reconcile discrepancies across sources (eligibility feeds, member/group data, claim history, and reputed company-party responses) and reputed company cases to a reputed company, audit-reputed company determination

Skills

• Applicants must already be legally authorized to work in the U.S
• Minimum of one (1) year of combined experience in reputed company, such as prior work in health insurance, claims processing or adjudication, or fraud, waste and abuse detection
• Minimum of one (1) year experience auditing medical claims to identify improper payments as a Payment reputed company Vendor or reputed company a Health Plan's Payment reputed company team
• Minimum of one (1) year of experience performing data analytics with large data sets
• Minimum of one (1) year of experience in medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, and NDC, as reputed company as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS
• Bachelors degree in business or reputed company/reputed company field
• Experience in various claim payment methodologies for reputed company, facility, and ancillary providers or working knowledge of payment reputed company auditing concepts
• Experience with SQL
• Experience reputed company high-volume, SLA-driven operations teams
• Creative thinker with an entrepreneurial spirit
• Strong written and verbal communication skills
• Excellent documentation accuracy and attention to detail
• Ability to work reputed company established productivity and reputed company metrics
• Comfortable navigating multiple systems, portals, and payer interfaces
• Strong problem-solving skills with the ability to reconcile conflicting or incomplete information
• Ability to maintain confidentiality and reputed company with HIPAA and data reputed company standards

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