Payment Integrity Analyst - Data Mining

Accountabilities:

• Investigate and validate moderate to complex payment integrity cases by analyzing claims data, contracts, billing records, and reimbursement policies to identify incorrect payments.

• Apply medical coding standards (CPT, ICD-10, HCPCS, DRG, and others) and payer guidelines to determine accurate reimbursement outcomes and document audit-ready justifications.

• Reconcile conflicting data sources, escalate edge cases when necessary, and ensure case resolution aligns with internal policies and regulatory requirements.

• Perform end-to-end case management of assigned data mining leads, ensuring timely resolution of high-volume and high-dollar claim issues.

• Collaborate with cross-functional teams to develop audit concepts, configure rules, and maintain documentation libraries supporting validation processes.

• Contribute to process optimization by identifying recurring errors, false positives, and opportunities for improved detection logic and workflow efficiency.

Requirements:

• 5+ years of experience in healthcare-related roles such as claims processing, health insurance operations, fraud/waste/abuse detection, or payment integrity.

• At least 3+ years of hands-on experience auditing medical claims or performing payment integrity casework involving moderate complexity cases.

• Strong experience analyzing large datasets and performing data-driven investigations in a high-volume operational environment.

• Solid understanding of medical billing and coding systems including CPT, ICD-10-CM/PCS, HCPCS, NDC, and healthcare reimbursement models such as DRG, OPPS, and MIPS.

• Strong analytical, problem-solving, and critical thinking skills with the ability to interpret complex or conflicting payment data.

• Excellent attention to detail, documentation accuracy, and ability to meet strict productivity and quality standards.

• Experience with query tools, reporting systems, or basic SQL for data analysis is highly desirable.

• Strong communication skills with the ability to clearly document findings and support audit or dispute processes.

Benefits:

• Competitive base salary range: $34.84 – $52.27 per hour

• Remote work flexibility within the United States

• Comprehensive medical, dental, and vision insurance options

• Paid time off and holidays

• 401(k) retirement savings plan

• Opportunities to contribute to impactful healthcare cost reduction initiatives

• Exposure to advanced data mining and payment integrity technologies

• Inclusive, mission-driven work environment focused on innovation in healthcare efficiency

How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
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