Job Title: Healthcare Data Analyst / Algorithm Developer

Position Summary
We are seeking a detail-oriented Healthcare Data Analyst / Algorithm Developer to support healthcare data analysis, coding logic development, and program integrity activities for medical coding, medical record review, and billing compliance functions. This role is responsible for analyzing claims and encounter data, developing and refining data-driven algorithms and review logic, identifying coding and billing patterns, and producing actionable insights to support clinical, operational, and financial decision-making.

The ideal candidate brings strong SQL and data analysis skills, a solid understanding of healthcare reimbursement data, and working knowledge of CPT, HCPCS, and ICD-10 coding concepts. This individual will work closely with coding, clinical, and audit teams to translate business rules and policy requirements into queries, logic models, audit targeting methodologies, dashboards, and analytic outputs. The role requires strong analytical thinking, attention to detail, and the ability to interpret healthcare data in support of audit readiness, payment integrity, and compliance monitoring.

Key Responsibilities

• Analyze healthcare claims, encounter, provider, and medical record-related data to identify trends, anomalies, outliers, and potential coding or billing compliance risks.

• Develop, test, validate, and maintain algorithms, business rules, and SQL queries used to support coding reviews, audit targeting, payment integrity, and compliance monitoring activities.

• Translate coding, reimbursement, and policy requirements into data logic that can be used to flag records, claims, or providers for further review.

• Support development of analytical models and rule sets related to CPT, HCPCS, ICD-10, modifiers, place of service, units, and other claims elements.

• Review data outputs for accuracy, reasonableness, and alignment with review objectives, audit scopes, and program policies.

• Partner with coders, auditors, clinicians, and compliance staff to understand review requirements and convert those requirements into repeatable analytic approaches.

• Identify patterns related to documentation deficiencies, claim errors, utilization anomalies, denial trends, overpayment risks, and potential fraud, waste, and abuse indicators.

• Prepare data files, summaries, scorecards, dashboards, and reports for internal stakeholders, audit teams, and program leadership.

• Support record selection methodologies for audits, sampling, monitoring, and focused reviews using claims and related data.

• Perform data validation, quality checks, reconciliation activities, and root cause analysis to ensure reliability of analytic outputs.

• Document query logic, technical methods, assumptions, and validation steps in a clear and reproducible manner.

• Assist with ad hoc analysis related to coding accuracy, reimbursement trends, provider billing patterns, and policy changes.

• Support maintenance of reference tables, edit logic, provider attributes, coding crosswalks, and other data assets used in analytics.

• Monitor impacts of coding and regulatory updates on data logic, algorithms, and analytic reporting.

• Collaborate with internal stakeholders to improve audit efficiency, targeting precision, and reporting clarity.

• Adapt quickly to changing priorities, evolving business rules, and new review requirements while meeting deadlines and maintaining quality.

Qualifications

• Bachelor’s degree in data analytics, health information management, informatics, public health, healthcare administration, statistics, computer science, or a related field preferred.

• At least 2 years of experience in healthcare data analysis, claims analysis, payment integrity, program integrity, revenue cycle analytics, or related work preferred.

• Strong experience with SQL required, including writing complex queries, joining large datasets, aggregating results, and validating outputs.

• Working knowledge of medical coding concepts, including CPT, HCPCS, and ICD-10, is strongly preferred.

• Experience working with healthcare claims or encounter data required; Medicaid experience is strongly preferred.

• Familiarity with healthcare billing, reimbursement, documentation review, audit support, or compliance monitoring preferred.

• Experience developing logic models, analytic rules, dashboards, or automated reporting solutions preferred.

• Proficiency in Microsoft Excel required, experience with data visualization and reporting tools preferred.

• Strong analytical, critical thinking, problem-solving, and organizational skills.

• Ability to communicate technical findings clearly to non-technical audiences.

• Strong attention to detail and ability to manage multiple datasets, priorities, and deadlines.

• Ability to work independently and collaboratively in a fast-paced environment.

Preferred Competencies

• Ability to translate complex healthcare policy and coding requirements into clear analytic logic.

• Strong understanding of claims structures, provider billing behavior, and reimbursement of data relationships.

• Experience identifying outliers, trend shifts, and risk indicators through targeted data analysis.

• Ability to prepare concise, decision-ready summaries of findings for operational and leadership audiences.

• Comfort working in an environment that combines data analytics, coding review, audit support, and compliance monitoring.

• Experience supporting initiatives related to payment integrity, fraud waste and abuse detection, utilization review, or billing compliance is strongly preferred.