Data Mining Consultant II (Client Lead)

Job Description

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members.

The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics.

Sagility has more than 25,000 employees across 5 countries.

A Payment Integrity Data Mining Consultant II, is a professional who is market/ client facing and responsible for identifying new audit opportunities, researching new pricing methodologies, and engaging with various work teams to generate systems automation and enhancement capabilities in our state-of-the-art audit workstation.

Data Mining Lead is an IC role which identifies, develops, and implements new concepts that recognize incorrect payments.

These concepts are developed based on industry experience, regulatory research, and the ability to analyze medical claim data to discover incorrect payments.

This role is responsible for analyzing client data and generating high quality recoverable claims, assisting in the identification, validation, and documentation of moderate to more complex recovery projects.

Job title:

Data Mining Consultant II (Client Lead)

Job Description:

Education:

High School Diploma or equivalent required.

BA/BS in Business Administration or related field or equivalent preferred but not necessary

Experience:

5+ year?s knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required

Mandatory Skills:


* Experience in Ideating & developing new auditing rules and paradigms.


* Experience in Business case analysis and help designing BRD.


* Experience in Pricing, COB, platform analytics.


* Experience of Validation of Rules through testing methodologies.


* Experience in auditing, payment processing, or financial fraud prevention is a must.


* Load and synthesize healthcare data from multiple sources.


* Experience working within a health plan, managed care organization, provider operated healthcare environment or third party administrator.


* Development of end to end payment Integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical record Management, Audit Operations, Recovery Operations, Provider Correspondence and Forecasting & Invoicing.


* Maintaining working knowledge of CMS transmittals, RAC, and OIG reports is a must.


* Prior claims auditing or consulting experience desirable in either a provider or payer environment.


* Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings.


* Work with audit teams and establish a process to ensure the concepts being deployed are working as expected with higher findings thus ensuri...