Data mining specialist (payment integrity)

The Data Mining Specialist role will require a high level of expertise in identifying, developing, and implementing effective data mining queries. This individual must have extensive knowledge across multiple lines of business, including Medicare, Medicaid, and Commercial claims, as well as experience navigating multiple claims payment systems. The role also requires the ability to analyze complex claims, identify payment anomalies and new recovery opportunities, and translate findings into accurate, actionable data mining concepts. These capabilities are critical to maintaining a strong pipeline of opportunities and adapting concepts and query logic across different client environments.

Base Pay Range: $93,900 - $134,100/yr

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits

RESPONSIBILITIES

• Access client claim systems to validate claim reimbursement terms as needed
• Routinely review client contract systems or files for contractual reimbursement terms
• Create overpayment rules for data mining
• Analyze payer data and identify anomalies or aberrant billing practices
• Perform an extensive review of client accounts to determine if correct payments were made to providers
• Accurately reprice complex claims utilizing multiple client claims systems to perform the tasks
• Identify work files to be audited through a query process
• Documentation of audit findings to be shared with client
• Serve as a resource for junior auditors and new employees
• Identify and develop/validate new overpayment opportunities and recovery concepts
• Serve as a client and program specific SME when called upon in both internal and external settings
• Evaluate current procedures for efficiency and accuracy as well as recommend solutions for process improvements
• Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security and Regulatory policies, procedures, and programs.

QUALIFICATIONS

Required:

• Minimum of 5 years employment within Payment Integrity Services
• Minimum 5-8 years or equivalent work experience in healthcare/payment integrity/managed care contracts
• Experience with Medicare, Medicaid, and Commercial claims data
• Experience with industry systems (FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, Pricers)
• Sound knowledge of ICD-10, CPT, and HCPC coding guidelines
• Experience with processing complex medical health claims
• Knowledge of CMS Pricing Guidelines and Coding Methodologies
• Attention to detail and ability to problem solve
• Excellent computer skills, proficient in excel, word, and outlook
• Excellent interpersonal skills, and communication skills
• Able to train and delegate
• Demonstrate ability to prioritize tasks
• Excellent organizational skills

Education:

• Bachelor’s degree or equivalent work experience in Payment Integrity services

What We Offer:

EXL Health offers an exciting, fast paced and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions. From your very first day, you get an opportunity to work closely with highly experienced, world class analytics consultants. You can expect to learn many aspects of businesses that our clients engage in. You will also learn effective teamwork and time-management skills - key aspects for personal and professional growth. We provide guidance / coaching to every employee through our mentoring program wherein every junior level employee is assigned a senior level professional as advisors. The sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond.

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com.

EXL never requires or asks for fees/payments or credit card or bank details during any phase of the recruitment or hiring process and has not authorized any agencies or partners to collect any fee or payment from prospective candidates. EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL’s Human Resources team, as well as our hiring managers.

EXL is the indispensable partner for leading businesses in data-led industries such as insurance, banking and financial services, healthcare, retail and logistics. We bring a unique combination of data, advanced analytics, digital technology and industry expertise to help our clients turn data into insights, streamline operations, improve customer experience, and transform their business. Our partnerships with clients are built on a foundation of collaboration – and we’ve been chosen as a partner by nine of the top ten leading US insurance companies, nine of the top 20 global banks, and six of the top ten US health care payers. We function as one team to make your goals our goals, whether that’s unlocking the value of generative AI or embedding analytics into workflows that reduce risk or power your growth. Clients choose EXL as their transformation partner for many reasons. Our geographic diversity make talent all over the world instantly accessible. Digital accelerators enable unmatched speed-to-value, letting you realize results fast. It’s our people that truly set us apart, though, including the 1,500 data scientists we have dedicated to our generative AI practice. And our more than twenty years of experience in delivering business services, garnering stellar client references, and maintaining a solid balance sheet are reassuring to our C-suite clients. Find out for yourself why clients, employees, and analysts think we’re some of the best in the business. Contact us to see how we can help you achieve your goals.