Job Title: Payment Integrity Auditor / Data Mining Auditor
Location: Remote
Schedule:
Full-time (40 hours/week) | Monday–Friday, 8:00 AM – 5:00 PMAbout the RoleWe are seeking a detail-oriented and analytical Data Mining Auditor to join our Audit Operations team. In this role, you will analyze paid medical claims data feeds received from providers on behalf of our health plan partners. Your core mission is to configure and refine "data traps" that pinpoint systemic overpayments, hospital billing errors, and payer configuration oversights—ensuring accurate reimbursement across complex provider contracts.
Key Responsibilities:
Overpayment Validation: Perform manual validation of flagged claims to confirm overpayments stemming from provider billing errors or payer system misconfigurations.
Complex Data Calculations: Execute, build, and maintain complex Excel calculation workbooks to recalculate claims and quantify financial impact accurately.
Contract & Reimbursement Interpretation: Analyze and interpret intricate payer-provider contracts, fee schedules, and reimbursement methodologies to establish claim logic and determine rule hierarchies.
Precedent Logic Navigation: Apply clinical and contractual rule hierarchies to evaluate high-complexity claim scenarios (e.g., emergency department visits, multiple surgical procedures, carve-outs).Audit Feedback Loop: Partner with internal data science and engineering teams to provide feedback, refining claims traps and improving automated detection models.
Required Qualifications:
1+ Years of Payment Integrity or Data Mining Audit Experience: Direct background identifying and auditing overpayments using health plan/payer claims data.
Payer/Health Plan Background: Hands-on audit experience specifically focused on the health plan, insurer, or payer side of operations.
Deep Reimbursement & Contract Knowledge: Proven ability to navigate complex payment methodologies (DRG, APC, Fee Schedule, Per Diem) and determine contract precedence during ambiguous billing situations.
Excel Proficiency: Demonstrated ability to navigate advanced Excel functions, build and maintain analytical workbooks, and execute manual calculations without error.
Preferred Qualifications:
Adjudication System Familiarity: Experience navigating legacy or modern claim adjudication engines (e.g., Facets, Proclaim, DOS, COBOL, AS400Medical Coding Credentials: Active coding certification through AAPC or AHIMA (e.g., CPC, CIC, COC, or CPCH).AI Tool Familiarity: Exposure to AI workflows, conversational AI/chatbots, structured data uploads, or automation tools to streamline daily audit tasks.
