Sagility · 1 day ago
Consultant II Data Mining
United States
Full-time
Remote
Senior Level
5+ years expSagility combines technology and BPM services with healthcare expertise to enhance member experiences. The Consultant II Data Mining is responsible for identifying audit opportunities, analyzing medical claim data, and generating high-quality recoverable claims while engaging with various teams for process improvements.
BillingConsultingHealth CareTechnical Support
Responsibilities
The Key responsibility for the role is market/ client facing
This role will be reviewing and analysing payment-related data using data mining techniques to ensure accuracy, compliance, and fraud prevention in financial transactions
Their primary objective is to ideate and perform audits on payment data, identify discrepancies, errors, and fraudulent activities, and provide recommendations for process improvement
This position is responsible for data collection, data analytics and data reporting for Data Mining programs including but not limited to COB, Duplicate, Contractual, billing errors, overlapping services etc
This position has to Influence leadership to adopt new ideas, and products as an experienced industry leader and provide executive level program updates and manage team escalations and operate as an industry thought leader in Payment Integrity
Qualification
Required
High School Diploma or equivalent required
5+ year's knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required
Experience in Ideating & developing new auditing rules and paradigms
Experience in Business case analysis and help designing BRD
Experience in Pricing, COB, platform analytics
Experience of Validation of Rules through testing methodologies
Experience in auditing, payment processing, or financial fraud prevention is a must
Load and synthesize healthcare data from multiple sources
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
Maintaining working knowledge of CMS transmittals, RAC, and OIG reports is a must
Prior claims auditing or consulting experience desirable in either a provider or payer environment
Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings
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
Excellent communication skills both oral and written
Strong interpersonal skills that will support collaborative teamwork
Microsoft Office Proficient: Word and Excel; Access – highly preferred
Ability to interpret and assess complex payment datasets
Excellent communication and interpersonal skills
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