Senior Data Mining & Payment Integrity Analyst

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

Summary
As a Senior Data Mining & Payment Integrity Analyst, you will design and develop data mining concepts that identify improper payments and improve claims accuracy across dental, medical, and pharmacy billing. Using your expertise in healthcare reimbursement, regulations, and data analysis, you will translate complex policies into scalable audit and analytics solutions. You will collaborate with cross functional teams to drive innovation, support client payment integrity strategies, and help safeguard healthcare resources for the populations our clients serve.

Your Role in Our Mission

• Develop and implement new data mining opportunities to identify overpayments to providers through data review and analytics across dental, medical, and pharmacy claims.
• Act as a senior member of the team and mentor lower-level analysts.
• Research industry standard guidelines, State and Federal regulations, and client billing and reimbursement policies to develop and configure improper payment algorithms.
• Review provider contracts to identify algorithms for the identification of contract-based overpayments.
• Implement current Payment Analytics concepts for new and existing clients while ensuring client policy is supportive and properly applied.
• Support the appeals, validation, and client services teams in resolving outstanding issues related to production queries.
• Ensure individual and departmental goals are consistently met or exceeded through collaboration with other team members and management.
• Review IT programming results for quality assurance and proof of concept validation.
• Document query results and prepare internal and external documentation and presentations related to new overpayment issues.
• Partner with internal operations and clinical teams to develop, implement, review, and audit protocols and internal review guidelines.
• Collaborate with engineers to develop and implement technological improvements that support the audit process.
• Contribute innovative ideas for improving existing audit processes and audit queries.

What We Are Looking For

• 5 years of Healthcare Payment Integrity and/or Data Mining experience.
• At least 3 years of Domain Specific experience in Medical, Dental, or Pharmacy claims analysis.
• Experience in Healthcare Auditing, including Reviewing and Validating the Accuracy of Claims Data and the Accuracy of Claims Payment, is preferred.
• Experience Applying Published Healthcare Guidelines such as CMS Regulations and Coding Guidelines to Healthcare Claims Data. Recovery audit experience is preferred.

The pay range for this position is $69,400.00 - $99,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.