Payment Integrity Data Mining Ideation SME (Healthcare)

TL;DR

Payment Integrity Data Mining Ideation SME (Healthcare): Developing data mining audits to ensure payment accuracy across Medicaid, Medicare, and Commercial lines with an accent on medical coding and reimbursement methodologies. Focus on creating precise audit concepts, defining data selection parameters, and validating results to identify improper payments.

Location: Remote (USA)

Salary: $80,000 – $100,000

Company

hirify.global provides specialized payment integrity and audit services to improve financial accuracy for healthcare payers.

What you will do

• Develop data mining audit opportunities based on Federal, State, and Client-specific rules and regulations.
• Define data selection requirements and validate outputs to ensure high accuracy and consistency.
• Serve as the data Subject Matter Expert (SME) for designated clients, managing approvals and ad-hoc requests.
• Create concept-specific training materials and provide ongoing education for production audit staff.
• Monitor audit performance, analyzing yield and appeal statistics to refine audit logic.
• Maintain expert-level knowledge of CPT, HCPCS, and ICD-10 coding guidelines.

Requirements

• 5+ years of complex claims processing or coding auditing experience in the health insurance industry.
• Current certification: AAPC (CPC or COC), AHIMA (CCS), or RHIT designation.
• Mastery of CPT, HCPCS, and ICD coding standards and their impact on payments.
• In-depth understanding of Medicare, Medicaid, and Commercial reimbursement methodologies.
• Expert level proficiency in data analysis and Excel.
• Ability to develop data mining audits and apply regulatory standards with objectivity.

Nice to have

• Python or SQL coding skills.
• Clinical background or healthcare experience.
• Experience with EDI transactions (837, 835).
• Proficiency with coding tools such as 3M, Webstrat, or Encoder.
• Experience in the Payment Integrity space.

Culture & Benefits

• Fully remote work arrangement.
• Collaboration across cross-functional teams including analytics and operations.
• Opportunity to manage high-impact audit concepts and drive payment accuracy.