Consultant

• We are seeking Consultants with foundational experience in healthcare claims data, including exposure to validating, loading, processing, and analyzing claims across various payer types (e.g., Medicare, Medicaid, VA, Commercial).
• This role supports the development and execution of claims analyses and audits aimed at reducing improper payments, identifying potential fraud, and uncovering patterns that inform payment policy and cost-saving strategies.
• Demonstrate working knowledge of claims datasets and healthcare reimbursement concepts.
• Assist in gathering and interpreting business and technical requirements for claims audits and post-payment analysis.
• Conduct data-driven and qualitative research to support payment policy evaluation and anomaly detection.
• Build dashboards and reports using coding tools to visualize claims trends and audit findings.
• Research and summarize industry-standard coding rules and contribute to reimbursement policy discussions.
• Document findings and support the development of recommendations and follow-up actions.
• Contribute to analytics that identify payment trends, errors, and improper payment risks.
• Stay informed on state healthcare reform efforts and emerging policy changes.
• Translate research and claims review insights into business requirements for analytics tools.
• Respond to inquiries and disputes related to claims edits and policy interpretation.
• Collaborate with internal teams and external stakeholders to support project delivery.
• Support project management activities and contribute to client interactions.

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