Note: The job is a remote job and is open to candidates in USA. EXL is a healthcare consulting and operations company that provides services to clients through experienced healthcare professionals. The Quality Analyst – Data Mining, Payment Integrity reviews audit findings, validates claim repricing and overpayment opportunities, analyzes quality trends, and ensures compliance with client, coding, pricing, and regulatory requirements. The role also provides feedback, recommends corrective actions, and supports process improvements and auditor performance.
Responsibilities
- Perform quality control reviews of completed Data Mining audit findings to validate claim accuracy, payment methodology, recovery opportunity, and compliance with client-specific requirements
- Review supporting documentation, including provider contracts, fee schedules, client claim systems, pricing references, coding guidelines, and audit notes to confirm findings are fully supported and clearly documented
- Validate complex claim repricing completed through Data Mining audit processes using applicable client claims systems, pricing tools, CMS guidelines, coding resources, and program-specific procedures
- Monitor, analyze, and report error trends, root causes, pass/fail outcomes, and recurring issues impacting payment accuracy, audit quality, and operational performance
- Recommend corrective actions, training opportunities, and quality improvement initiatives to reduce payment errors, strengthen audit consistency, and improve overall performance
- Evaluate current audit processes, controls, procedures, and Data Mining concepts; review query-driven audit outputs to ensure effectiveness, consistency, efficiency, compliance with quality expectations, and alignment with recovery outcomes
- Partner with audit leadership, trainers, and subject matter experts to clarify requirements, recommend process improvements, support calibration efforts, and contribute to quality initiatives, procedure updates, and special projects
- Ensure audit work aligns with client, program, regulatory, HIPAA, and company requirements while maintaining confidentiality and compliance standards
Skills
- High School Diploma required
- Minimum 5+ years of experience in medical claims, healthcare auditing, Payment Integrity, coding, claim quality review, or related healthcare operations
- Strong understanding of complex medical claim processing, provider payment methodologies, claim systems, and audit documentation requirements
- Ability to interpret client requirements, provider contracts, fee schedules, coding guidelines, pricing rules, and healthcare compliance standards
- Strong verbal and written communication skills with the ability to provide clear, professional, and actionable feedback
- Ability to work independently, manage multiple priorities, meet deadlines, and maintain accuracy in a production-based environment
- Extensive knowledge of medical claims processing, healthcare reimbursement methodologies, provider payment logic, and overpayment recovery concepts
- Strong understanding of CMS pricing and reimbursement guidelines, provider contract interpretation, fee schedules, and claim payment methodologies
- Knowledge of CPT, HCPCS, ICD-10-CM, and medical coding methodologies; ICD-9 knowledge helpful where applicable
- Proficiency with Microsoft Excel, PowerPoint, Outlook, Word, spreadsheets, databases, and data analysis tools
- Ability to review query-driven audit outputs and understand how Data Mining logic supports claim selection, overpayment identification, audit validation, and quality outcomes
- Exceptional analytical and critical-thinking skills with the ability to identify patterns, root causes, quality trends, process improvement opportunities, and corrective actions
- Demonstrated commitment to accuracy, quality, attention to detail, confidentiality, and compliance with client, company, and healthcare requirements
- Experience analyzing complex healthcare claims, including large healthcare claims datasets and payment trend information
- Strong understanding of quality assurance principles, audit accuracy standards, QC criteria, error prevention, and quality review guidelines
- Effective written and verbal communication skills with the ability to provide clear, constructive feedback and collaborate professionally with auditors, leaders, trainers, and client-facing teams
- College degree preferred
- CPC (Certified Professional Coder) or other nationally recognized coding certification preferred. Relevant experience may be considered in lieu of certification
- Experience with Payment Integrity, healthcare reimbursement, or overpayment recovery audits preferred
- Prior experience performing quality reviews, claim audits, or audit validation strongly preferred
- Experience applying quality criteria, audit scorecards, accuracy standards, or preferred structured quality review guidelines
- Experience with healthcare claim systems and industry tools such as FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat/Webtrat, and applicable pricers preferred
Benefits
- 100% Remote (U.S.-based)
- An exciting, fast paced, and innovative environment
- Opportunity to work closely with highly experienced, world class Healthcare consultants
- Opportunities to learn effective teamwork and time-management skills for personal and professional growth
- Guidance/coaching through a mentoring program wherein every junior-level employee is assigned a senior-level professional as an advisor
- Growth and development opportunities in the company and beyond
Company Overview
Company H1B Sponsorship