Senior Manager - Data Mining & Exploratory Intelligence

Sr Manager Data Mining & Exploratory Intelligence

Role Overview

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.

Key Responsibilities

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

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

Required Qualifications

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