Concept and Edit Analyst, Data Mining

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care, and improving access for all. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense. We geek out over building and perfecting software that helps health plans succeed, but we also understand the irreplaceable value of human intelligence.  Penstock is an Equal Opportunity Employer.

Role and Responsibilities

The Concept and Edit Analyst serves as a subject matter expert responsible for the development, production auditing, validation, and continuous improvement of Penstock concepts and edits used to support claim selection across all claim, provider, and review types. This role is focused on ensuring that selection logic is not only analytically sound, but also effective, accurate, and actionable in a live production audit environment. A key responsibility of this position is to evaluate concept and edit performance through data mining, audit feedback, production results, and outcome analysis. The Concept and Edit Analyst identifies opportunities to improve logic accuracy, reduce non-actionable selections, strengthen audit yield, and ensure alignment with payment integrity objectives.

This position partners closely with the Concept/Edit Development team, Audit team, Project team, and IT team to ensure that Penstock concepts and edits reliably identify coding, billing, and documentation errors that contribute to improper payments. By combining concept development expertise with production auditing oversight, this role helps drive consistent, high-quality, and defensible audit outcomes across all lines of review. Key responsibilities include: 

• Participates in the concept and edit development lifecycle, including researching new concepts, designing and refining selection logic, validating edits in production, documenting review criteria and rationale, and creating and maintaining associated production audits.
• Conducts data mining and analytical reviews to validate concept performance, identify trends and anomalies, and surface new recovery opportunities.
• Develops, maintains, and audits concept logic and applicable code sets to ensure alignment with intended business rules, reimbursement methodologies, and audit objectives.
• Serves as a dedicated production auditor, executing audits aligned to developed concepts and edits and ensuring accuracy, consistency, and quality in audit results.
• Develops and evaluates concepts and edits related to common payment integrity scenarios, including but not limited to: Frequency, Unit Based Concepts, etc.
• Researches and applies federal and state regulations, payor medical and administrative policies, provider contracts, and coding and billing standards to support concept integrity and defensibility.
• Analyzes audit and production results, identifies opportunities for concept or edit refinement, and updates logic and documentation as appropriate to improve performance.
• Partners with IT when system changes, data anomalies, or logic limitations are identified that may impact concept accuracy or audit execution.
• Assists with monthly claim selection and ongoing production support activities as needed.
• Contributes to and supports training efforts related to new or enhanced concepts and edits for the Audit team.
• Develops and utilizes analytical tools and reporting to monitor concept performance and drive continuous improvement.
• Stays current on coding, reimbursement, clinical, and industry changes that may impact existing concepts or inform new development opportunities.
• Provides subject matter expertise and guidance to Audit and Concept/Edit Development team members and supports broader payment integrity initiatives across the organization.
• Actively supports the Penstock mission by identifying and advancing high-quality, data-driven concepts and edits that promote accuracy, consistency, and integrity between payors and providers.

Qualifications and Education Requirements

• Bachelor’s Degree in Health Informatics or Health Information Management, or equivalent formal education and experience  
• Current AHIMA or AAPC coding credential(s)
• 5 or more years of coding and/or auditing experience (or demonstrated equivalent)
• Experience with reimbursement policies and methodologies across different settings, such as inpatient, outpatient, skilled nursing, professional, etc.
• Experience with reviewing and interpreting federal and state rules and regulations, payor medical and administrative policies, provider contracts, and coding and billing standards
• Comprehensive understanding of Official Coding Guidelines, AHA Coding Clinic, and CPT assistant
• Experience, or familiarity, with structured query language (SQL) preferred
• Experience with collecting, analyzing, and interpreting claim and audit data
• Understanding of HIPAA, and all rules and practices regarding the safeguarding of PHI/PII
• Ability to communicate kindly and effectively with all levels of the organization
• Experience training, preparing, and delivering presentations
• Proficient with Microsoft Word, Excel, and PowerPoint
• Able to work Eastern time zone hours
• Secure and private home office with reliable high-speed internet connection

Penstock is an affiliate company of Goodroot, which launches and grows companies dedicated to putting patients back in the center of healthcare.

About Goodroot

Goodroot is a community of companies committed to delivering more access to better healthcare at a lower cost. With a growing group of brands including, but not limited to Penstock, Navion, and Emry, Goodroot is reshaping healthcare for good, one system at a time. Learn more at www.goodrootinc.com.