Job Summary:
The FWA Payment Integrity Data Analyst III is responsible for developing, implementing, managing and presenting in-depth analyses that meet the information needs associated with Fraud, Waste and Abuse.
Essential Functions:
Lead and implement data analytic Ideation and R&D activities and strategy to support decision-making across multiple lines of business and clients to enable FWA growth.
Validate Program Integrity vendor deliverables, results and collaborate with PI vendors to understand and drive CareSource FWA analytic needs and results, function as consultant to propose business solutions, and communicate results of data analytics outcomes against goals and strategic plan.
Participate in analytical, experimental, investigative, and other fact-finding work in support of concept development and in conjunction with vendors.
Monitor emerging internal and external FWAE data vulnerabilities and trends which may impact CareSource and create solutions to mitigate risk.
Identify trends and patterns using standard corporate, processes, tools, reports, and databases as well as leveraging other processes and data sources
Research policies, coding guidelines, and regulations that would support the hypothesis being developed.
Conduct outcome analyses to determine impact and effectiveness of corporate and SIU initiatives.
Collaborate on the examination and explanation of complex data relationships to answer questions identified either within the department or by other departments as it relates to Fraud Waste and Abuse.
Generate graphics that effectively describe, explore, and summarize analysis for communication to appropriate parties.
Manage processes and reporting to ensure that claims associated with investigations are processed appropriately and in a timely manner.
Collaborate with the Legal Department, generating data and analyses to support Legal proceedings.
Perform data analyses in support of both the SIU Program Integrity and Audit Functions.
Incorporate critical thinking skills and judgment in the analysis process to determine best course of action for each inquiry/problem.
Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques that will reveal intelligence for identification of any associative or causal relationships pertaining to Fraud Waste and Abuse and Error, providing management level summaries that explain key findings and providing documentation for use during Audits.
Use descriptive statistical techniques to measure impact of various actions/studies, internal and external, develop sampling and hypothesis testing to help the organization determine outcomes.
Performs any other job related duties as requested.
Education and Experience:
Bachelor's degree or equivalent years of relevant work experience in Healthcare Data Analytics required
Seven (7) years of experience in data analysis, FWA Ideation and/or analytic programming required
Seven (7) years Health care delivery and/or payer experience required
Extensive experience with Data Visualization / Dashboard tools (Power BI) required
Extensive experience using SQL for analytics projects, including databases queries required
Three (3) years of experience with Medicare/Medicaid required
Healthcare management experience/exposure required
Clinical experience is preferred
Competencies, Knowledge and Skills:
Proven understanding of database development including: Implementing Database Relationships; Data Integration; Data Manipulation using SQL; Database Object Creation using SQA; Database Normalization; Dimensional Design Concepts
Insight in administering Microsoft SQL Server, Transact-SQL (ANSI-SQL) and Integration Services (SSIS) is required
Insight and understanding of in programming languages such as Microsoft Visual Basic, Python
Strong Knowledge of coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and…