Senior Analyst (Data mining)

5+ years experience in healthcare data mining or claims editing. Deep understanding of provider contracts (rate structures, carve-outs, methodologies). Strong knowledge of claims processing, coding, billing, and payment logic. Proven ability to identify improper payment patterns and root causes. Strong investigative and deductive reasoning skills. Comfortable collaborating with technical teams. Self-directed, detail-oriented, and adaptable. Working proficiency in SQL (preferred).

Lead pre and post-pay claim reviews to identify inaccurate payments. Analyze and interpret provider contracts for payment accuracy. Collaborate with engineering and data science teams to translate logic into frameworks. Research and document emerging reimbursement and contract patterns. Translate complex reimbursement and contract scenarios into structured rules. Analyze claim-level data to pinpoint root causes of overpayments/denials. Maintain expertise on CMS and commercial payer reimbursement guidelines. Support quality review, concept validation, and process improvement.