MedReview Inc.

Auditor

• Conduct thorough data audits to ensure accuracy in claims processing and resolution.
• Analyze large datasets to identify patterns, discrepancies, and trends related to claims performance.
• Work closely with team members to share insights, collaborate on problem-solving, and contribute to discussions regarding claims audits.
• Resolve claims discrepancies by determining whether claims are underpaid or overpaid, providing clear documentation of findings.
• Maintain high standards of accuracy and efficiency while following established leadership guidelines.
• Prepare and present audit findings and recommendations to leadership in a clear and concise manner.

Data Mining Auditor

Data Scientist

• Collaborate with stakeholders to identify business challenges that can be solved through data analysis.
• Gather data from various sources (SQL databases, APIs, web scraping), then clean and "wrangle" it to ensure accuracy for modeling.
• Design and implement algorithms and predictive models using machine learning techniques to forecast outcomes or categorize information.
• Analyze datasets to uncover hidden patterns, trends, and anomalies.
• Translate technical findings into "data stories" using tools like Tableau or Power BI to influence executive decisions.

Analyst

Data Mining Analyst

Business Intelligence Developer

• Design, develop, and maintain efficient data models and ETL/ELT processes
• Write complex SQL queries and ClickHouse functions
• Utilize Python for data cleaning, transformation, and automation of BI tasks
• Create interactive dashboards and reports using BI tools
• Translate stakeholder needs into actionable BI solutions
• Ensure data accuracy, integrity, and security
• Collaborate with clinicians and operational leaders
• Perform deep-dive analyses to support strategic decision-making

Business Intelligence Analyst – Developer

Data Engineer

• Design, implement, and maintain end-to-end data pipelines on Azure, ensuring high availability and low latency for healthcare claim and analytics processing.
• Manage and optimize ClickHouse as our primary analytical engine.
• Structure data environments to support the full ML lifecycle.
• Collaborate with Data Scientists to implement automated CI/CD pipelines for model deployment, monitoring, and retraining.
• Develop scalable frameworks to ingest diverse healthcare data sources with high velocity.
• Ensure all data structures and processes adhere to HITRUST/HIPAA standards.

• Conduct thorough quality assessments of healthcare claims data, focusing on identifying overpayments through data mining techniques.
• Develop, implement, and execute quality assurance plans and test cases specific to healthcare claims data mining.
• Collaborate with data analysts and business partners to analyze claims data for potential overpayments and ensure compliance with client policies.
• Identify and document any discrepancies or anomalies in claims data, coordinating with cross-functional teams for resolution.
• Conduct root cause analysis on detected overpayments and develop reports summarizing findings and recommendations for process improvements.
• Monitor and evaluate data mining processes, providing innovative solutions to enhance data accuracy and quality assurance in healthcare claims.
• Prepare and present detailed quality assurance reports and metrics to stakeholders, highlighting trends and areas for improvement.
• Foster strong working relationships with various business partners, ensuring effective communication and collaboration on claims data integrity initiatives.

Quality Analyst – Data Mining

• Collaborate with ML engineers and data platform teams to design, implement, and maintain the feature store architecture for both offline (batch) and online (real-time) use cases.
• Identify, define, and engineer high-quality features from various raw data sources (databases, APIs, streaming data) using statistical analysis and domain knowledge.
• Partner with database administrators, clinical experts, data scientists, ML engineers, and business stakeholders to promote feature reuse, define governance standards, track feature lineage, and ensure data consistency across models.
• Build and optimize ingestion and transformation pipelines using distributed data frameworks to populate the feature store, ensuring data accuracy, reliability, and freshness.
• Generate training and testing datasets from the feature store and work with ML engineers to ensure seamless feature serving for model inference in production environments.
• Develop monitoring and alerting frameworks to track feature data quality, integrity, and latency, proactively identifying and resolving issues.
• Document feature definitions, data sources, and usage best practices, and effectively communicate complex technical concepts and insights to technical and non-technical audiences.

Data Scientist – Analyst

• Perform detailed coding audits on outpatient facility claims to validate appropriate CPT/HCPCS, revenue codes, modifiers, and ICD-10 coding in accordance with CMS, NCCI, and payer-specific rules.
• Evaluate medical record documentation to ensure services are coded, billed, and reimbursed accurately.
• Identify and analyze payment integrity issues including overpayments, underpayments, and incorrect billing patterns.
• Collaborate with clinical, data analytics, and payment integrity teams to develop new outpatient claim review concepts and audit strategies.
• Provide education and feedback to internal teams or providers based on audit findings.
• Research and apply current CMS OPPS, APC, and EAPG guidelines to ensure compliant auditing practices.
• Document audit findings clearly and concisely, maintaining a high standard of accuracy and quality assurance.
• Contribute to the development and testing of audit tools, rule logic, and automated review concepts to enhance outpatient claim accuracy.
• Stay current with regulatory updates, coding changes, and payer policy revisions.

Outpatient Coder Auditor

Director

• Develop and lead a comprehensive quality assurance and compliance program for PI operations (DRG review, HBA, COB, IBR, data mining, edit engines).
• Establish and manage audit routines, quality checks, and error tracking mechanisms.
• Implement remediation plans to address systemic issues and drive continuous improvement.
• Ensure compliance with CMS guidelines, NCCI edits, LCD/NCD policies, payer rules, and internal standards.
• Partner with the Delivery Manager to enforce production discipline and reporting controls.
• Collaborate with the Business Analyst to document quality workflows, SOPs, and acceptance criteria.
• Analyze quality metrics and produce dashboards/reports for leadership on accuracy, compliance, and error trends.
• Serve as the compliance subject matter expert, keeping the team current on regulatory and payer policy updates.
• Lead training sessions and workshops to improve staff accuracy, compliance, and adherence to standards.

Quality Director – Payment Integrity

• Lead the planning, execution, and delivery of PI projects and operational initiatives.
• Partner with Business Analysts to translate documented requirements (BRDs, FRDs, user stories) into actionable delivery plans.
• Coordinate across operations, IT, QA, and data teams to ensure alignment and accountability.
• Establish and track key performance metrics (savings, accuracy, timeliness, client satisfaction).