Data Mining Ideation Specialist (Healthcare)

Location: Remote

Salary: $90,000–$110,000 annually

Company

hirify.global provides payment integrity services, including DRG Validation, Cost Outlier, Readmission Review, and overpayment recovery solutions for healthcare clients.

What you will do

• Identify and develop data mining audit concepts across Medicare, Medicaid, and Commercial lines of business.
• Define data-selection criteria, audit logic, and claim parameters for accurate improper-payment identification.
• Validate audit outputs, monitor performance, and recommend logic improvements and enhancements.
• Serve as a subject matter expert for clients and designated audit concepts, supporting approvals and client requests.
• Develop training materials and support quality assurance, education, and concept implementation.
• Collaborate with analytics, audit, operations, and client services teams on new payment integrity opportunities.

Requirements

• At least five years of experience in complex claims processing, claims auditing, medical coding, or healthcare payment integrity.
• Mastery of CPT, HCPCS, and ICD coding standards, medical claims, reimbursement methodologies, and billing regulations.
• Current coding certification required: CPC, COC, CCS, or RHIT.
• Knowledge of Medicare, Medicaid, and Commercial health insurance plans, provider contracting, compliance requirements, and payer policies.
• Experience interpreting NCDs, LCDs, NCCI PTP Edits, MUEs, DRG, APC, and EAPG methodologies, and related payment regulations.
• Advanced Microsoft Excel and data analysis skills, with strong analytical, organizational, communication, and problem-solving abilities.

Nice to have

• Experience with Python, SQL, or other data analysis and reporting tools.
• Clinical healthcare experience or previous payment integrity industry experience.
• Knowledge of EDI 837 and 835 claim formats.
• Experience with 3M, WebStrat, Encoder, or similar coding and audit platforms.
• Experience translating technical concepts into training materials and documentation.

Culture & Benefits

• Collaborative environment focused on healthcare accuracy, accountability, clinical excellence, and continuous improvement.
• Medical, dental, and vision insurance.
• 401(k) retirement plan, life and disability insurance, and flexible spending accounts.
• Paid time off, company holidays, and an employee assistance program.
• Opportunities for professional growth and meaningful work improving healthcare payment outcomes.