Data Mining Ideation Specialist

Position Summary

At Med Review, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As a leader in payment integrity solutions, we provide DRG Validation, Cost Outlier, Readmission Review, and Payment Integrity services to healthcare clients nationwide.

Under the direction of Payment Integrity leadership, the Data Mining Ideation Specialist is responsible for identifying and developing data mining audit concepts that promote payment accuracy across Medicaid, Medicare, and Commercial lines of business. This role leverages expertise in medical coding requirements, claims adjudication processes, reimbursement methodologies, and healthcare regulations to identify improper payment opportunities with a high degree of accuracy and consistency.

The Data Mining Ideation Specialist collaborates with audit, analytics, and operations teams to develop new over payment recovery opportunities, define data selection parameters, validate audit results, and support ongoing quality and education initiatives. Success in this role requires strong analytical skills, extensive coding knowledge, attention to detail, and the ability to interpret complex healthcare reimbursement policies and regulations.

• Leverage Federal, State, local, and client-specific regulations, contracts, policies, and reimbursement guidelines to identify new data mining audit opportunities.
• Develop and define data selection criteria and audit logic requirements to ensure accurate claim identification.
• Validate audit outputs and results to ensure integrity, consistency, and payment accuracy.
• Serve as a subject matter expert for designated clients and audit concepts.
• Assist with obtaining client approvals and responding to client requests related to audit concept development and performance.
• Develop and maintain concept-specific training materials for audit staff and operational teams.
• Monitor audit performance and identify opportunities for ongoing improvements, enhancements, and logic revisions.
• Maintain expertise in CPT, HCPCS, and ICD-10 coding guidelines, healthcare reimbursement methodologies, and claim submission requirements.
• Collaborate with analytics, operations, audit, and client services teams to identify and implement new payment integrity opportunities.
• Research emerging healthcare regulations, coding updates, and reimbursement policy changes that may impact audit development.
• Support quality assurance initiatives and provide guidance regarding audit accuracy and concept implementation.
• Perform additional projects and duties as assigned.

• Minimum of five (5) years of complex claims processing, claims auditing, medical coding, or payment integrity experience within the healthcare industry.
• Knowledge of Medicare, Medicaid, and Commercial health insurance plans and reimbursement methodologies.
• Prior experience developing payment integrity, data mining, or reimbursement audit concepts strongly preferred.
• Mastery of CPT, HCPCS, and ICD coding standards and guidelines.
• Current coding certification required, including one of the following:
  • AAPC Certified Professional Coder (CPC)
  • AAPC Certified Outpatient Coder (COC)
  • AHIMA Certified Coding Specialist (CCS)
  • Registered Health Information Technician (RHIT)
• Expert understanding of medical claim coding and its impact on claim reimbursement and payment accuracy.
• Strong knowledge of healthcare claim processing, billing regulations, reimbursement methodologies, and provider contracting principles.
• Knowledge of legal, regulatory, compliance, and documentation requirements related to medical coding and billing practices.
• Experience interpreting reimbursement policies, payer edits, and regulatory guidance, including:
  • National Coverage Determinations (NCDs)
  • Local Coverage Determinations (LCDs)
  • NCCI Procedure-to-Procedure (PTP) Edits
  • Medically Unlikely Edits (MUEs)
  • DRG, APC, and EAPG reimbursement methodologies
  • Multiple Surgery Reductions
  • Three-Day Payment Window regulations
  • Eligibility and Coordination of Benefits (COB) requirements
• Advanced proficiency in Microsoft Excel and data analysis techniques.
• Strong analytical, organizational, and problem-solving skills.
• Excellent verbal, written, and interpersonal communication skills.
• Exceptional attention to detail and commitment to quality.
• Ability to effectively manage multiple priorities in a fast-paced environment.

• Experience with Python, SQL, or other data analysis and reporting tools.
• Clinical healthcare experience or…