Note: The job is a remote job and is open to candidates in USA. Codoxo provides artificial intelligence-driven solutions for detecting and reducing healthcare fraud, waste, abuse, and improper payments. The Payment Integrity Quality Assurance Analyst – Data Mining performs quality assurance, data validation, and analytical reviews of Medicaid claims and payment integrity data mining activities. The role evaluates algorithms, investigative leads, payment edits, and recovery opportunities while identifying trends, anomalies, and data quality issues.
Responsibilities
- Perform quality assurance reviews of Medicaid payment integrity data mining results, claims analytics, and investigative leads
- Validate data mining findings to determine whether identified claims, providers, members, services, or transactions represent potential improper payments or other payment integrity concerns
- Conduct detailed claims-level analysis to identify billing patterns, utilization anomalies, coding issues, duplicate claims, unbundling, upcoding, medically unlikely services, excessive utilization, and other potential overpayment scenarios
- Apply Medicaid reimbursement policies, state and federal regulations, clinical guidelines, coding rules, and payment policies when evaluating claims
- Perform pre- and post-implementation QA testing of payment integrity rules, edits, algorithms, and analytical solutions
- Reconcile claims data across multiple sources and investigate discrepancies involving eligibility, provider, member, service, authorization, payment, and encounter data
- Develop and execute test cases and quality assurance plans for new and existing payment integrity initiatives
- Analyze trends in Medicaid claims and provider behavior to identify emerging payment integrity risks and opportunities
- Support development and refinement of data mining methodologies designed to detect fraud, waste, abuse, and improper payments
- Conduct retrospective analysis to determine the financial impact and effectiveness of payment integrity initiatives
- Validate potential overpayment opportunities prior to referral for recovery, provider outreach, audit, or investigation
- Document analytical methodology, testing procedures, findings, recommendations, and validation results in accordance with organizational standards
- Work collaboratively with business stakeholders to translate payment integrity requirements into measurable data and quality assurance criteria
- Perform root-cause analysis on data quality and payment integrity issues and recommend corrective actions
- Assist with regulatory, audit, compliance, and client reporting related to Medicaid payment integrity activities
- Maintain current knowledge of Medicaid policies, reimbursement methodologies, coding practices, and emerging payment integrity trends
- Apply knowledge of Medicaid fee-for-service and managed care claims environments
- Analyze Medicaid encounters, claims, eligibility, provider, authorization, and payment data
- Evaluate payment integrity opportunities involving Medicaid-specific billing and reimbursement requirements
- Review claims against applicable state Medicaid policies, federal requirements, provider agreements, and reimbursement methodologies
- Support payment integrity initiatives involving high-risk Medicaid provider types, services, and utilization patterns
- Understand the relationship between Medicaid managed care organizations, state Medicaid agencies, providers, third-party administrators, and downstream payment integrity vendors
- Identify potential discrepancies between billed services, authorized services, rendered services, and reimbursed services
- Support validation of Medicaid encounter data and downstream payment integrity analytics
- Maintain awareness of CMS and state Medicaid program requirements affecting claims payment, data quality, and payment integrity
Skills
- • Bachelor's degree in Healthcare Administration, Business, Finance, Analytics, Information Systems, or a related field, or equivalent experience
- • 3+ years of experience in healthcare claims, payment integrity, claims analytics, quality assurance, data analysis, SIU, fraud/waste/abuse, or related healthcare operations
- • Medicaid experience required
- • Demonstrated experience analyzing healthcare claims and identifying payment anomalies or improper payment patterns
- • Experience performing quality assurance, data validation, testing, or audit activities
- • Strong understanding of healthcare claims processing and reimbursement methodologies
- • Ability to analyze large and complex datasets and identify trends, patterns, and anomalies
- • Strong analytical, problem-solving, and investigative skills
- • Excellent written and verbal communication skills
- • Strong attention to detail and ability to manage multiple analytical projects simultaneously
- • Experience with Medicaid managed care and/or Medicaid fee-for-service programs
- • Experience with payment integrity data mining
- • Experience with SIU investigations or investigative analytics
- • Experience with claims editing and payment integrity solutions
- • Knowledge of CPT, HCPCS, ICD-10-CM/PCS, DRG, NCCI, MUE, modifier usage, and other healthcare coding methodologies
- • Experience with claims platforms, healthcare data warehouses, or payment integrity technologies
- • Knowledge of CMS Medicaid requirements and state-specific Medicaid reimbursement policies
- • Remote Work Requirements: To ensure reliable performance on the company-issued CODOXO laptop, employees working remotely must have a stable high-speed internet connection
- • Physical Requirements: Work is performed in an office environment (either in our office or work-from-home) and requires the ability to work on a computer, operate standard office equipment, and work at a desk
- • Certified Professional Coder (CPC), Certified Professional in Healthcare Quality (CPHQ), or similar certification is a plus
Benefits
- Health, Dental, and Vision insurance with 100% employee premium coverage (Starts Day 1)
- Unlimited PTO
- Annual Professional Development stipend
- Annual home office stipend
- 401K Match (after 90 days)
Company Overview