Join Optum, a global leader in health optimization, and contribute to improving health outcomes through technology. You’ll be part of an inclusive culture with talented colleagues, comprehensive benefits, and significant career development opportunities. This role focuses on developing and evaluating clinical rules to identify aberrant billing and fraud patterns within healthcare claims data. Make a tangible impact on communities and advance global health.

Your work will involve leveraging domain expertise and advanced data mining techniques to refine and enhance clinical rules. You will also play a crucial role in stakeholder management, project delivery, and quality assurance to ensure robust analytic solutions and improved accuracy of existing analytics.

Develop and evaluate clinical deterministic and probabilistic rules for healthcare claims data to detect fraudulent patterns.

Identify opportunities for business impact through data mining and advanced analytics.

Build and maintain strong relationships with global analytics teams and business stakeholders.

Manage team dynamics and ensure effective project delivery with a focus on quality assurance.

Communicate analytic findings and address client concerns effectively, both orally and in writing.

Conduct secondary research to identify potential overpayment scenarios and develop recurring algorithms.

Develop metrics to forecast new algorithm profitability and design technical specifications for data manipulation.

Provide clinical and technical consulting to business leaders, ensuring appropriate encapsulation of information.

Collaborate closely with Business Analysts and Domain SMEs to define reporting requirements and ensure specifications are complete and achievable.

A Bachelor's degree in a related Information Technology field, Healthcare, or Clinical Research is required.

Possess a medical coding/clinical certification such as CIC/COC or equivalent knowledge.

Minimum of 7 years of experience in clinical data analysis on diverse healthcare data types, with a focus on building or optimizing clinical solutions.

Over 4 years of experience in data analytics and claims processes, including identifying data anomalies and performing root cause analysis.

Experience with Scrum or other Agile development methodologies.

Proficiency in analytical tools and techniques, with the ability to handle medium to large datasets.

In-depth understanding of the US healthcare system, payment integrity processes, claim lifecycle, and adjudication.

Working knowledge of basic SQL or SAS is essential.

Demonstrated strong project management skills and the ability to influence cross-functionally.

Excellent analytical, complex thinking, problem-solving, and troubleshooting abilities are crucial.

Proven excellent written and verbal communication skills, along with strong organizational skills and attention to detail.