Data Mining Consultant I

Data Mining Consultant I at Sagility

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 Data Mining Consultant I is a market/client-facing professional 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. This IC role 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.

Education

• High School Diploma or equivalent required.
• BA/BS in Business Administration or related field or equivalent preferred but not necessary.

Experience

• 4-5+ years knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required.

Mandatory Skills

• Prior claims auditing or consulting experience desirable in either a provider or payer environment.
• Excellent communication skills both oral and written.
• Strong interpersonal skills that will support collaborative teamwork.
• Microsoft Office Proficient: Word and Excel; Access – highly preferred.
• Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings.
• Collaborate & Establish strong relationships with internal and external stakeholders to define, align and delivery payment accuracy initiatives.
• Work with audit teams and establish a process to ensure the concepts being deployed are working as expected with higher findings thus ensuring higher hit rates and findings rates on the concepts deployed.

Preferred Skills

• Knowledge of payment systems, financial transactions, and claims processes end to end.
• Understanding of payment integrity concepts and fraud detection methodologies.
• Experience in auditing, payment processing, or financial fraud prevention is a plus.
• 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.

Roles & Responsibilities

• Utilizing healthcare experience to perform audit recovery procedures.
• Identify overpaid claims.
• Identifying and defining issues, developing criteria, reviewing, and analyzing contracts and Health Plan reimbursement policies and the various state and federal regulations.
• Entering and documenting the incorrect payment issue into Devlin’s systems accurately and in accordance with standard procedures.
• Updating and developing new and current audit recovery report ideas and then working with the IT team to automate the process.
• Researching reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings.

Key skills/competency

• Payment Integrity
• Claims Auditing
• Data Analysis
• Healthcare Reimbursement
• Fraud Prevention
• Microsoft Excel
• Microsoft Access
• Client Engagement
• Process Improvement
• Regulatory Research