Concept and Edit Analyst, Data Mining

1. About Our Client:

The organization operates in the healthcare payment integrity sector, addressing inefficiencies and improper payments in health plans and provider claims. It develops software and services that support recovery, audit, and regulatory teams by ensuring accuracy in claim selection and payment processes. The organization aims to reduce wasted healthcare spending, lower care costs, and improve access by promoting transparency and integrity in payment systems.

2. About the Opportunity:

The Concept and Edit Analyst, Data Mining role focuses on developing, validating, and improving claim selection concepts and edits to enhance payment integrity audits. This position ensures that selection logic is accurate, actionable, and aligned with audit objectives, contributing to effective detection of coding, billing, and documentation errors. The role supports consistent, high-quality audit outcomes by partnering with various teams and analyzing data to refine concepts and edits.

3. Responsibilities:

• • Participate in concept and edit development lifecycle including research, design, validation, and documentation
• • Conduct data mining and analytical reviews to assess concept performance and identify recovery opportunities
• • Develop, maintain, and audit concept logic and code sets for alignment with business rules and audit goals
• • Execute production audits to ensure accuracy and consistency
• • Develop and evaluate concepts related to payment integrity scenarios
• • Research and apply relevant federal and state regulations, policies, contracts, and coding standards
• • Analyze audit data to identify and implement improvements
• • Collaborate with IT to address system or data issues impacting audits
• • Support monthly claim selection and production activities
• • Assist in training efforts related to new or enhanced concepts and edits
• • Develop analytical tools and reporting for monitoring performance
• • Stay updated on coding, reimbursement, clinical, and industry changes
• • Provide subject matter expertise and support broader payment integrity initiatives
• • Promote high-quality, data-driven concepts that enhance accuracy and integrity

4. Requirements:

• • Bachelor’s Degree in Health Informatics, Health Information Management, or equivalent
• • Current AHIMA or AAPC coding credentials
• • 5+ years of coding and/or auditing experience or equivalent
• • Knowledge of reimbursement policies across various healthcare settings
• • Experience interpreting federal/state regulations, payor policies, provider contracts, and coding standards
• • Comprehensive understanding of Official Coding Guidelines, AHA Coding Clinic, and CPT assistant
• • Preferred experience with SQL
• • Skills in collecting, analyzing, and interpreting claim and audit data
• • Understanding of HIPAA and PHI/PII safeguarding practices
• • Effective communication skills across organizational levels
• • Experience in training and delivering presentations
• • Proficiency in Microsoft Word, Excel, and PowerPoint
• • Ability to work Eastern time zone hours
• • Secure home office with reliable high-speed internet

5. Pay Range and Compensation Package:

• The pay range and compensation package for this role will be determined based on the candidate’s experience, skills, and other relevant factors.

Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.

Note:

RemoteHunter is not the Employer of Record (EOR) for this role. Our purpose in this opportunity is to connect exceptional candidates with leading employers. We help job seekers worldwide discover roles that match their goals and guide them to complete their full application directly through the hiring company’s career page or ATS.