Key Responsibilities

• Analyze healthcare claims, encounter, provider, and medical record-related data to identify trends, anomalies, outliers, and potential coding or billing compliance risks.
• Develop, test, validate, and maintain algorithms, business rules, and SQL queries used to support coding reviews, audit targeting, payment integrity, and compliance monitoring activities.
• Translate coding, reimbursement, and policy requirements into data logic that can be used to flag records, claims, or providers for further review.
• Support development of analytical models and rule sets related to CPT, HCPCS, ICD-10, modifiers, place of service, units, and other claims elements.
• Review data outputs for accuracy, reasonableness, and alignment with review objectives, audit scopes, and program policies.
• Partner with coders, auditors, clinicians, and compliance staff to understand review requirements and convert those requirements into repeatable analytic approaches.
• Identify patterns related to documentation deficiencies, claim errors, utilization anomalies, denial trends, overpayment risks, and potential fraud, waste, and abuse indicators.
• Prepare data files, summaries, scorecards, dashboards, and reports for internal stakeholders, audit teams, and program leadership.
• Support record selection methodologies for audits, sampling, monitoring, and focused reviews using claims and related data.
• Perform data validation, quality checks, reconciliation activities, and root cause analysis to ensure reliability of analytic outputs.
• Document query logic, technical methods, assumptions, and validation steps in a clear and reproducible manner.
• Assist with ad hoc analysis related to coding accuracy, reimbursement trends, provider billing patterns, and policy changes.
• Support maintenance of reference tables, edit logic, provider attributes, coding crosswalks, and other data assets used in analytics.
• Monitor impacts of coding and regulatory updates on data logic, algorithms, and analytic reporting.
• Collaborate with internal stakeholders to improve audit efficiency, targeting precision, and reporting clarity.
• Adapt quickly to changing priorities, evolving business rules, and new review requirements while meeting deadlines and maintaining quality.

Qualifications

• Bachelor’s degree in data analytics, health information management, informatics, public health, healthcare administration, statistics, computer science, or a related field preferred.
• At least 2 years of experience in healthcare data analysis, claims analysis, payment integrity, program integrity, revenue cycle analytics, or related work preferred.
• Strong experience with SQL required, including writing complex queries, joining large datasets, aggregating results, and validating outputs.
• Working knowledge of medical coding concepts, including CPT, HCPCS, and ICD-10, is strongly preferred.
• Experience working with healthcare claims or encounter data required; Medicaid experience is strongly preferred.
• Familiarity with healthcare billing, reimbursement, documentation review, audit support, or compliance monitoring preferred.
• Experience developing logic models, analytic rules, dashboards, or automated reporting solutions preferred.
• Proficiency in Microsoft Excel required, experience with data visualization and reporting tools preferred.
• Strong analytical, critical thinking, problem-solving, and organizational skills.
• Ability to communicate technical findings clearly to non-technical audiences.
• Strong attention to detail and ability to manage multiple datasets, priorities, and deadlines.
• Ability to work independently and collaboratively in a fast-paced environment.