Data Mining Analyst
Full Job Posting
What You’ll Do
- 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.
- 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.
What You Bring
- 2+ years of 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.
About Machinify
Healthcare intelligence company providing AI-powered payment integrity solutions to health plans.
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