Data Mining Ideation Specialist

• Leverage Federal, State, Local, and Client-specific contracts, rules, regulations, and policies to identify data mining audit opportunities.
• Define data selection requirements and validate output to ensure accurate selections.
• Become a data SME for designated Client(s).
• Assist with obtaining Client approvals and any ad-hoc Client requests.
• Develop concept-specific training materials for audit staff.
• Monitor audit performance to ensure ongoing accuracy and to assess potential logic revisions.
• Maintain expertise on CPT, HCPCS, and ICD-10 Coding guidelines, other claim submission requirements, and reimbursement methodologies.

• 5+ years of complex claims processing and/or coding auditing experience in the health insurance industry.
• Knowledge of all payer types including Medicare, Medicaid, and Commercial plans.
• Prior experience in payment integrity audit development is highly preferred.
• Mastery of CPT, HCPCS, and ICD coding standards.
• Current Coding Certification:
  • AAPC Certified Professional Coder (CPC), Certified Outpatient Coder (COC) certification, or
  • Certified Coding Specialist (CCS) certification through AHIMA or
  • RHIT designation
• Expert level understanding of medical claim coding and its impact on claim payments, including in-depth understanding of various reimbursement methodologies and the direct impact of incorrect coding.
• Ability to develop data mining audits, apply regulatory standards, and contractual requirements with credibility and objectivity.
• Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures and documentation.
• Knowledge of health insurance operations, specifically with claims processing, billing, reimbursement, or provider contracting.
• Prior experience in payer edit development, and/or reimbursement policy experience. For example:
  • CMS policies and practices, including NCD’s and LCD’s, NCCI Edits for PTP and MUE, and DRG, APC, EAPG groupers
  • Multiple Surgery Reductions
  • 3-Day Payment Window
  • Eligibility and COB
• Expertise in data analysis and EXCEL.
• Strong analytical and problem-solving abilities.
• Effective communication skills.
• Meticulous attention to detail.

• Python or SQL coding skills.
• Clinical background or experience.
• Demonstrated experience translating technical jargon to non-technical end users.
• Previous experience in the Payment Integrity space.
• Exposure to EDI transactions (837, 835).
• Experience using coding tools (such as 3M, Webstrat, and Encoder)
• Collaborative mindset and ability to work effectively across cross- functional teams.
• Proficiency in Outlook, Word, Excel, and other applications.
• Ability to work independently and can multi-task or transition to different tasks easily.

• Develop and deliver 6+ new audit concepts monthly, including logic specifications aligned with reimbursement policies
• Submit 4+ high-impact audit concepts per month, contributing to a minimum of $975K in identified overpayment opportunities
• Partner with internal teams to move concepts from ideation to client review and production implementation 
• Ensure timely communication and follow-through: 
  • Respond to inquiries within 1 business day 
  • Complete research and provide updates within 3 business days 
  • Drive resolution, including logic revisions or claim actions, within 5 business days 
• Monitor audit performance, including yield and appeal outcomes, and continuously refine logic for accuracy and impact
• Collaborate with Operations and Management to support audit effectiveness and quality initiatives 
• Complete "Second Look" reviews within established turnaround times 

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