FWA Payment Integrity Data Analyst III, Health Plan, SQL

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟠 Senior

🔴 Lead

📉 Data Analyst

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Lead and implement data analytic ideation and research-and-development activities and strategy supporting decision-making across multiple lines of business and clients • Validate Program Integrity vendor deliverables and results • Collaborate with Program Integrity vendors to understand and drive FWA analytic needs and results • Propose business solutions and communicate data analytics outcomes against goals and strategic plans • Participate in analytical, experimental, investigative, and fact-finding work supporting concept development and vendor collaboration • Monitor emerging internal and external FWA data vulnerabilities and trends and create risk-mitigation solutions • Identify trends and patterns using corporate processes, tools, reports, databases, and other data sources • Research policies, coding guidelines, and regulations supporting analytical hypotheses • Conduct outcome analyses to determine the impact and effectiveness of corporate and SIU initiatives • Examine and explain complex data relationships related to Fraud, Waste and Abuse • Generate graphics that describe, explore, and summarize analyses • Manage processes and reporting to ensure investigation-related claims are processed appropriately and timely • Collaborate with the Legal Department by generating data and analyses supporting legal proceedings • Perform data analyses supporting SIU Program Integrity and Audit Functions • Apply critical thinking and judgment to determine the best course of action for each inquiry or problem • Review reports and data for patterns, special-cause variation, trends, and associative or causal relationships related to Fraud, Waste and Abuse and Error • Provide management-level summaries explaining key findings and documentation for audits • Use descriptive statistics, sampling, and hypothesis testing to determine outcomes • Perform other job-related duties as requested

🎯 Requirements

• 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 of healthcare delivery and/or payer experience required • Extensive experience with Data Visualization / Dashboard tools (Power BI) required • Extensive experience using SQL for analytics projects, including database queries required • Three (3) years of experience with Medicare/Medicaid required • Healthcare management experience/exposure required • Clinical experience is preferred • Proven understanding of database development, including database relationships, data integration, SQL data manipulation, database object creation, database normalization, and dimensional design concepts • Insight in administering Microsoft SQL Server, Transact-SQL (ANSI-SQL), and Integration Services (SSIS) required • Insight and understanding of programming languages such as Microsoft Visual Basic and Python • Strong knowledge of coding standards, billing rules and regulations, and procedure and diagnosis codes (CPT, ICD10, HCPCS, APC and DRGs) • Proven analytic skills in solving multi-dimensional problems • Advanced experience with Microsoft Excel, Access, Word, and PowerPoint • SAS and SQL skills • Graphic development/presentation skills • Knowledge of inferential statistics • Working knowledge of descriptive statistical applications and techniques • Data mapping skills • Ability to document database and application design • Ability to maintain documentation of changes and modifications • Critical listening, thinking, verbal, and written communication skills • Decision-making/critical-thinking skills • Ability to work independently and within a team environment • Knowledge of Medicaid, Medicare, and managed care • Ability to lead analytic efforts • Coding certification through AAPC or AHIMA preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support

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