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EXL este o companie de consultanță și servicii pentru afaceri care ajută organizațiile să utilizeze datele, analizele și tehnologia pentru a-și îmbunătăți operațiunile și a lua decizii mai bune. Activitatea sa include managementul operațiunilor, analiza decizională și transformarea digitală, având experiență în sprijinirea clienților din domeniul sănătății, al asigurărilor, al finanțelor și al logisticii. EXL combină știința datelor cu expertiza practică în afaceri pentru a dezvolta soluții adaptate obiectivelor, modelului operațional și contextului sectorial al fiecărei organizații.
Senior Manager, Claims Data Mining and Payment Integrity
Lead claims analytics and exploratory data mining to detect Medicare, Medicaid, and commercial overpayments. Turn payment-integrity expertise into practical solutions for analytics and product teams.
Descriere
- Lead exploratory analysis of paid claims data to uncover utilization patterns, anomalies, and potentially inappropriate or excessive payments
- Apply expertise in CMS regulations, contract interpretation, reimbursement, and claims workflows to direct data-mining and investigative work
- Reverse-engineer claims outcomes to identify the root causes of payment issues and system behavior
- Convert operational and claims findings into actionable use cases and solution concepts for analytics and product teams
- Work with analytics, product, and strategy partners to align solutions with real-world claims operations
- Assess analytical findings against practical claims and payment conditions
- Present insights, risks, and opportunities clearly to technical and non-technical audiences
- Help improve and scale claims monitoring and overpayment-detection capabilities
Cerințe
- At least 10 years of U.S. healthcare claims experience, with a strong focus on adjudication and payment-integrity data mining
- Broad experience working with Medicare, Medicaid, or commercial healthcare business
- Established expertise in end-to-end claims review, auditing, and payment integrity
- Ability to detect patterns, anomalies, and inappropriate payments in large claims datasets
- Strong analytical judgment and the ability to connect operational expertise with data science
- Experience working across analytics, product, strategy, and compliance functions
- Excellent communication skills for explaining complex claims concepts to varied audiences
- Previous participation in payment-integrity data-mining or recovery initiatives
- Experience supporting or developing non-clinical claims analytics or data-mining programs
- Deep understanding of CMS rules, contract interpretation, reimbursement, and claims workflows
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