Job Description
Provides data & informatics support and analyses including quality matrices, outcomes studies and program evaluations, internal and external reporting, monitoring data trends and identifying patterns, performing modeling, recommending improvement solutions.
Essential Functions & Responsibilities
- Detailed knowledge of health care claiming rules for both medical and pharmacy and familiarity with both the requirements for and data on health care claiming forms
- An understanding of third-party adjudication process
- Ability to independently research and interpret claiming regulations and rules at both Federal and local level
- Ability to identify potential overpayment scenarios in the payment of medical and pharmacy claims. Individual will also design and conduct the data analyses required to support the identified overpayments.
- Monitor data trends, perform statistical analyses and prepare reports to facilitate Centers for Medicare and Medicaid Services (CMS) contract requirements.
- Experience in applying Correct Coding Initiative (CCI) or Outpatient Code Editor (OCE) or Medically Unlikely (MUE) edit a plus
- Experience with manipulating and analyzing large datasets.
- Ability to prepare Medical Loss Ratio Reports for multiple contracts.
- Provide subject matter expertise on analyzing, vetting, and understanding healthcare data.
- Develop and deploy analysis methods for detecting healthcare waste, fraud, and abuse
- Form and support robust opinions with imperfect data while still revising your beliefs in the face of compelling new data or analyses
- Actively review and suggest improvements to current or planned systems and processes based on your knowledge of healthcare claims data
- Collaborates with clients, development team and product management on a regular basis.
- Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
- Ability to come to work and work the regular schedule and shift for the position.
- Compliance with all personnel policies and procedures.
- Perform additional duties and related essential duties as assigned.
Required Education and Experience
- Bachelors or Masters degree in related field
- Three (3) years of experience with analyzing healthcare data – this experience should include work in at least 2 of the following areas:
- Fee-for-Service claims analysis
- Encounter claims analysis
- Enrollment
- Medicare crossover claims
- MCO, federal, or other state Medicaid data
- HEDIS Rate Calculation/Score Improvement
- Testifying to, vetting, or certifying data analyses for use in litigation or policymaking
- Proficiency in at least one statistical analysis, scripting, or programming language (R, PHP, Java, Python, Matlab, SAS, etc) or expertise in relevant tool (Excel, Business Objects, Access) required.
- SQL proficiency required. SQL Server Standard 2014.
- Well versed in healthcare compliance and HIPAA
- HEDIS Experience Preferred
- Expert knowledge of state and federal laws and regulations pertaining to Medicaid
- Demonstrated communication and presentation skills
- Applicant may be subject to a government security clearance investigation
- At least two years prior experience in health care claiming field, either with a provider of medical or pharmacy services or at a payer for health care claims, including a state Medicaid Management Information System (MMIS) or as a consultant to either providers or payers.