Overview
A Payment Accuracy Data Mining (DM) Specialist is part of a Data Mining Business Unit focused on configuring custom claim reviews to identify billing compliance issues related to regulations and contracted policies across various products, markets, and provider types.
This role involves auditing client data to generate high-quality recoverable claims. Under direct supervision, the specialist identifies and inputs recovery claims, voids, or other over- and underpayment types. The position requires documenting relevant facts and conclusions to support the work and validate claims, as well as communicating audit recommendations to supervisory auditors for evaluation and continuous learning. Professional skepticism is essential to enhance the quality of work and achieve success.
Responsibilities
- Work under direct supervision with monitoring for efficiency and quality of assigned tasks.
- Develop and maintain a basic understanding of Centers for Medicare and Medicaid Services (CMS) and National Association of Insurance Commissioners (NAIC) guidelines to determine correct liability order.
- Utilize audit tools such as Recovery Management System (RMS) and client-specific systems to complete audits.
- Review simple to medium proprietary reports and demonstrate proficiency in Microsoft Excel and client applications.
- Audit standard reports and paid claims to identify overpayments and underpayments, covering areas such as Data Mining, Claim Adjudication, Contract Compliance, Provider Billing & Duplicate Payment Reviews, Policy & Reimbursement Analysis, and Quality Assurance.
- Meet or exceed productivity and quality standards, including hit rate, number of claims written, and identification per hour.
- Prepare and evaluate responses to client disputes internally and externally as needed.
- Build proficiency in provider contracts and vendor agreements to make recommendations on medical policy applications, state and federal statutes, and reimbursement methodologies.
- Maintain a basic understanding of the healthcare industry and demonstrate a track record of delivering results.
- Adhere to organizational policies, procedures, and external regulatory requirements.
- Ensure confidentiality and security of all data in compliance with HIPAA laws.
- Maintain a safe work environment in accordance with industry standards.
Qualifications
- High School Diploma required.
- Bachelor’s degree preferred.
- Minimum of 1-2 years related healthcare experience preferred.
- Prior experience within the organization (1-2 years) recommended for internal candidates.
- Knowledge of Coordination of Benefits and healthcare industry experience preferred.
- Proficiency in Microsoft Office (Word, Excel, Outlook).
- Excellent verbal and written communication skills.
- Strong interest in working with large data sets and various databases.
- Ability to work independently and collaboratively in a team environment with self-motivation.
Mental Requirements
- Effective communication to exchange information.
- Ability to assess accuracy, neatness, and thoroughness of assigned work.
Physical Requirements and Working Conditions
- Ability to remain stationary, often standing or sitting for prolonged periods.
- Repetitive motions involving wrists, hands, and/or fingers.
- Must provide a dedicated, secure work area.
- Must have high-speed internet access and maintain an appropriate office setup.
- No adverse environmental conditions expected.
Compensation and Benefits
- Base pay ranges from $21.00 to $24.00 per hour, determined by experience, education, skills, certifications, and business needs.
- Eligible for discretionary bonus consideration.
- Nonexempt employees qualify for overtime pay as applicable.
- Benefits include medical, dental, vision, disability, and life insurance coverage; 401(k) savings plans; paid family leave; 9 paid holidays per year; and 17-27 days of Paid Time Off (PTO) annually, depending on level and tenure.
Location
Remote work with requirements to maintain a secure home office and high-speed internet connectivity.
Application Information
Applications are reviewed on a rolling basis. The anticipated application window closes on 5/26/2026 but may close earlier if a qualified candidate is selected or based on application volume.
Date of posting: 5/18/2026