Manager
About the Role
We are seeking a Claims Domain subject matter Expert in our CRE – Concept research & exploratory team within our Datamining COE for exploratory claims analysis and support the development of advanced data mining capabilities. This role will focus on identifying claims patterns, anomalies, and potential overpayments across Medicare, Medicaid and commercial business, while translating deep operational insight into actionable analytics concepts and solutions. The ideal candidate brings extensive hands-on claims experience and can “reverse engineer” claims behavior to inform data-driven strategies, tools, and controls.
Key Skills for This Role
Full Job Posting
Key Responsibilities
- Lead exploratory analysis of claims paid data to identify utilization patterns, anomalies, and potential overpaid or inappropriate claims
- Apply deep knowledge of CMS rules, contract interpretation, reimbursement, and workflows to guide data mining and investigative efforts
- Perform reverse engineering of claims outcomes to understand root causes of payment issues and system behaviors
- Translate operational and claims insights into clear use cases, concepts, and solution ideas for analytics and product teams
- Partner closely with analytics, product, and strategy teams to ensure solutions align with real-world claims operations
- Validate data-driven findings against practical claims and payment realities
- Clearly communicate insights, risks, and opportunities to both technical and non-technical stakeholders
- Support ongoing refinement and scaling of claims monitoring and overpayment detection capabilities
- Lead development and execution of data mining strategies. Ensure alignment with organizational goals. Manage a larger team of data professionals. Represent data mining team in executive meetings. Provide insights to drive business decisions. Develop long-term plans for data mining initiatives.
Qualifications
- Bachelor�s degree in Data Science, Computer Science, Statistics, or a related field. 4-6 years of experience in data mining or data analysis.
- 7+ years of experience in US healthcare claims with a strong focus on claims adjudication and Data Mining payment Integrity
- Extensive experience across Medicare, Medicaid or commercial business
- Demonstrated expertise in 360-degree claims review, auditing, and payment integrity
- Proven ability to identify patterns, anomalies, and inappropriate payments within large claims datasets
- Strong analytical mindset with the ability to bridge operations and data science
- Experience collaborating with cross-functional teams (analytics, product, strategy, compliance)
- Excellent communication skills with the ability to explain complex claims concepts clearly
- Prior involvement in payment integrity data mining or recovery initiatives
- Experience supporting or designing claims analytics or data mining non-clinical programs
Required Qualifications
- 7+ years of experience in US healthcare claims with a strong focus on claims adjudication and Data Mining payment Integrity
- Extensive experience across Medicare, Medicaid or commercial business
- Demonstrated expertise in 360-degree claims review, auditing, and payment integrity
- Proven ability to identify patterns, anomalies, and inappropriate payments within large claims datasets
- Strong analytical mindset with the ability to bridge operations and data science
- Experience collaborating with cross-functional teams (analytics, product, strategy, compliance)
- Excellent communication skills with the ability to explain complex claims concepts clearly
- Prior involvement in payment integrity data mining or recovery initiatives
- Experience supporting or designing claims analytics or data mining non-clinical programs
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