Extensive experience across Medicare, Medicaid or commercial business • 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 data mining or recovery initiatives • Experience supporting or designing claims analytics or data mining non-clinical programs Key Responsibilities • Lead exploratory analysis of claims paid data to identify utilization patterns, anomalies, and potential overpaid or inappropriate claims • Apply deep knowledge of CMS rules, contract interpretation, 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 • 7+ years of experience in US healthcare claims with a strong focus on claims adjudication and Data Mining payment Integrity