Payment Integrity Analyst – Data Mining

Role Overview

• The Payment Integrity Analyst (Data Mining) supports the Data Mining (DM) program by investigating payment errors due to incorrect processing of payment policies, contract terms, billing and/or coding errors to prevent and recover improper claim payments.
• This role performs hands-on casework in a high-volume environment including outreach, documentation, and system updates, while applying analytical skills to interpret claims and eligibility data, identify trends, and recommends process improvements that improve accuracy for the data mining program.
• Review, prioritize, and independently work assigned DM leads (automated and manual), including moderate-to-complex and high-dollar cases, to determine verification steps and next actions.
• Investigate and validate payment terms (Inpatient, Outpatient, Professional, Ancillary) using internal systems, payer portals, contracts, and other approved data sources.
• Apply payment policies, contract terms and coding guidelines, including CMS and AMA guidance as applicable, to determine the correct reimbursement and document the rationale for the payment determination.
• Reconcile discrepancies across sources (contract data and paper forms, conflicting policy and contract terms) and drive cases to a clear, audit-ready determination; escalate edge cases per policy.
• Analyze claim inventory from identification to resolution. Assist in developing concept overviews and analysis.
• Collaborate with team to configure client specific business rules. Assist in compiling sample claims and supporting documentation for Client review and approval.
• Maintain a library that includes instructions for validating specific audit concepts. Create clear, detailed, and accurate case notes that capture verification steps, evidence, and outcomes in internal tools to support audits and downstream recovery/reprocessing.
• Provide validated DM outcomes that support downstream payment integrity activities (recovery, reprocessing, adjustments) with minimal rework.
• Prepare and evaluate documentation needed for inquiries, disputes, and appeals related to determinations, as assigned.
• Meet or exceed established productivity, turnaround time, and quality/audit standards while managing a high-volume case queue.
• Track outcomes and error categories, identify root causes of recurring DM issues and false positives, and recommend opportunities to streamline research, improve data quality, and reduce incorrect payments. Use Excel and other tools to support ad hoc analysis (e.g., trend review, inventory quality checks, and performance insights); partner with stakeholders to clarify requirements and improve workflows.
• Reconcile discrepancies across sources (eligibility feeds, member/group data, claim history, and third-party responses) and drive cases to a clear, audit-ready determination.

Requirements

• Minimum of one (1) year of combined experience in healthcare, such as prior work in health insurance, claims processing or adjudication, or fraud, waste and abuse detection
• Minimum of one (1) year experience auditing medical claims to identify improper payments as a Payment Integrity Vendor or within a Health Plan’s Payment Integrity team.
• Minimum of one (1) year of experience performing data analytics with large data sets
• Minimum of one (1) year of experience in medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, and NDC, as well as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS
• Comfortable navigating multiple systems, portals, and payer interfaces.
• Ability to maintain confidentiality and comply with HIPAA and data security standards.