The Quality Analyst – Data Mining, Payment Integrity plays a key role in ensuring the accuracy, quality, and consistency of audit work performed within the Data Mining program. This position is responsible for reviewing completed audit findings, validating overpayment opportunities, confirming claim repricing accuracy and supporting documentation, and ensuring audit work aligns with client requirements, coding guidelines, pricing rules, and claim payment methodologies. The ideal candidate brings strong healthcare claims knowledge, analytical thinking, attention to detail, and the ability to provide clear feedback that supports auditor performance, continuous improvement, and stronger recovery outcomes.
Salary Range: $75,000 – $90,000 (based on experience, skills, and qualifications)
Location: 100% Remote (U.S.-based)
Up to 10% annual travel (for team meetings and limited client onsite engagements.)
For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits
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.
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.
This role is ideal for a detail-oriented quality professional who enjoys validating audit accuracy, identifying trends, and helping teams improve outcomes.
What we offer:
The posted range is the hiring range for this role — a subset of the broader range available to employees over time — and reflects base salary across our national hiring scale. Final offers are based on several factors, including the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position. The top of the range is reserved for candidates who notably exceed the requirements; the lower end applies to those with less experience or fewer preferred qualifications. For positions based in higher-cost zones (e.g., California, New York, New Jersey), actual compensation may exceed the posted range; your recruiter will share specifics during the process.
