Senior Analyst
New
M
MachinifyHealthcare Intelligence
Work from anywhere in the US!Full-TimeSenior
Salary not disclosed
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Job Details
- Experience
- 5+ years
- Required Skills
- SQL
Requirements
- 5+ years experience in healthcare data mining or claims editing on the provider, payer, or vendor side
- Deep understanding of provider contracts, including rate structures, carve-outs, and reimbursement methodologies.
- Strong knowledge of claims processing, coding, billing, and payment logic across CMS and commercial payers.
- Proven ability to identify improper payment patterns, root causes, and opportunities for correction.
- Strong investigative and deductive reasoning skills; able to connect policy, data, and contractual details.
- Comfortable working in close collaboration with technical teams to guide implementation of business logic.
- Self-directed, detail-oriented, and adaptable to a fast-paced, growing environment.
- Coding or billing certifications (Preferred).
- Working proficiency in SQL for data exploration and validation (Preferred).
- Prior work in cross-functional R&D or innovation teams focused on healthcare payment integrity (Preferred).
Responsibilities
- Lead pre and post-pay claim reviews to identify inaccurate payments using reimbursement and contract expertise.
- Analyze and interpret provider contracts to ensure payments align with negotiated terms, methodologies, and payer rules.
- Collaborate closely with engineering and data science teams to translate business and reimbursement logic into analytical and automation frameworks.
- Research and document emerging reimbursement and contract patterns, coverage rules, and billing practices to inform concept development.
- Translate complex reimbursement and contract scenarios into structured rules and business logic for implementation.
- Analyze claim-level data to pinpoint root causes of overpayments or incorrect denials and recommend corrective approaches.
- Maintain expertise on CMS and commercial payer reimbursement guidelines.
- Support quality review, concept validation, and process improvement initiatives.
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