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 Data mining 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 over payments 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 over payment 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