Data Mining & Exploratory Intelligence Manager

Extensive experience across Medicare, Medicaid or commercial business

• Demonstrated expertise in 360-degree claims review, auditing, and payment integrity

• Proven ability to identify patterns, anomalies, and inappropriate payments within large claims datasets

• Strong analytical mindset with the ability to bridge operations and data science

• Experience collaborating with cross-functional teams (analytics, product, strategy, compliance)

• Excellent communication skills with the ability to explain complex claims concepts clearly

• Prior involvement in payment integrity data mining or recovery initiatives

• Experience supporting or designing claims analytics or data mining non-clinical programs

Required Qualifications

• 7+ years of experience in US healthcare claims with a strong focus on claims adjudication and Data Mining payment Integrity

Key Responsibilities

• Lead exploratory analysis of claims paid data to identify utilization patterns, anomalies, and potential overpaid or inappropriate claims

• Apply deep knowledge of CMS rules, contract interpretation, reimbursement, and workflows to guide data mining and investigative efforts

• Perform reverse engineering of claims outcomes to understand root causes of payment issues and system behaviors

• Translate operational and claims insights into clear use cases, concepts, and solution ideas for analytics and product teams

• Partner closely with analytics, product, and strategy teams to ensure solutions align with real-world claims operations

• Validate data-driven findings against practical claims and payment realities

• Clearly communicate insights, risks, and opportunities to both technical and non-technical stakeholders

• Support ongoing refinement and scaling of claims monitoring and overpayment detection capabilities