We are seeking a seasoned Claims Domain Subject Matter Expert in our CRE – Concept research & exploratory team within our Datamining COE for exploratory claims analysis and support the development of advanced data mining capabilities. This role will focus on identifying claims patterns, anomalies, and potential overpayments across Medicare, Medicaid and commercial platforms, while translating deep operational insight into actionable analytics concepts and solutions.
The ideal candidate brings extensive hands-on claims experience and can “reverse engineer” claims behavior to inform data-driven strategies, tools, and controls.
Base Pay Range: $93,900- $154,200
For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits
Lead exploratory analysis of claims data to identify utilization patterns, anomalies, and potential overpaid or inappropriate claims
Apply deep knowledge of billing rules, coding, reimbursement, and workflows to guide data mining and investigative efforts
Perform reverse engineering of claims outcomes to understand root causes of payment issues and system behaviors
Translate operational and claims insights into clear use cases, concepts, and solution ideas for analytics and product teams
Partner closely with analytics, product, and strategy teams to ensure solutions align with real-world claims operations
Validate data-driven findings against practical claims and payment realities
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Clearly communicate insights, risks, and opportunities to both technical and non-technical stakeholders
Support ongoing refinement and scaling of claims monitoring and overpayment detection capabilities
10+ years of experience in operations with a strong focus on claims adjudication and payment Integrity
Extensive experience across Medicare, Medicaid or/ and commercial platforms
Demonstrated expertise in 360-degree claims review, auditing, and payment integrity
Proven ability to identify patterns, anomalies, and inappropriate payments within large claims datasets
Strong analytical mindset with the ability to bridge operations and data science
Experience collaborating with cross-functional teams (analytics, product, strategy, compliance)
Excellent communication skills with the ability to explain complex claims concepts clearly
Prior involvement in payment integrity, SIU, or recovery initiatives
Experience supporting or designing claims analytics or data mining programs
Familiarity with common coding schemes, authorization models, and provider billing behaviors
The posted base salary range is the hiring base salary range for this role. 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.
