Sagility · 2 months ago
Payment Integrity Data Mining Consultant I
United States
Full-time
Remote
Mid Level
4+ years expSagility is a company that combines technology and BPM services with healthcare expertise to enhance member experiences. The Payment Integrity Data Mining Consultant I is responsible for identifying audit opportunities, analyzing medical claim data, and generating recoverable claims while collaborating with various teams to enhance audit processes.
BillingConsultingHealth CareTechnical Support
Responsibilities
Utilizing healthcare experience to perform audit recovery procedures
Identify overpaid claims
Identifying and defining issues, developing criteria, reviewing, and analyzing contracts and Health Plan reimbursement policies and the various state and federal regulations
Entering and documenting the incorrect payment issue into Devlin’s systems accurately and in accordance with standard procedures
Updating and developing new and current audit recovery report ideas and then working with the IT team to automate the process
Researching reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings
Qualification
Required
High School Diploma or equivalent required
4 -5+ year's knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required
Prior claims auditing or consulting experience desirable in either a provider or payer environment
Excellent communication skills both oral and written
Strong interpersonal skills that will support collaborative teamwork
Microsoft Office Proficient: Word and Excel; Access – highly preferred
Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings
Collaborate & Establish strong relationships with internal and external stakeholders to define, align and delivery payment accuracy initiatives
Work with audit teams and establish a process to ensure the concepts being deployed are working as expected with higher findings thus ensuring higher hit rates and findings rates on the concepts deployed
Preferred
BA/BS in Business Administration or related field or equivalent preferred but not necessary
Knowledge of payment systems, financial transactions, and claims processes end to end
Understanding of payment integrity concepts and fraud detection methodologies
Experience in auditing, payment processing, or financial fraud prevention is a plus
Experience working within a health plan, managed care organization, provider operated healthcare environment or third party administrator
Development of end to end payment Integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical record Management, Audit Operations, Recovery Operations, Provider Correspondence and Forecasting & Invoicing
Company
Sagility
Sagility is a technology and a transformation company that provides BPM services for healthcare centers.
10001+ employees
H1B Sponsorship
Sagility has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (6)
2023 (6)
Funding
Current Stage
Public CompanyTotal Funding
unknown2024-11-12IPO
2021-01-01Acquired
Leadership Team
Ramesh Gopalan
Group Chief Executive Officer
Recent News
Business Standard India
2025-12-11
Business Standard India
2025-11-14
Company data provided by crunchbase