197 applicants

Company

CareSource · 6 hours ago

Senior Manager, Payment Integrity Analytics (Power BI required)

United States

Full-time

Remote

Senior Level

$90K/yr - $158K/yr

7+ years exp

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Comp. & Benefits

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Responsibilities

Develop and execute Analytic/Ideation and vendor analytic strategy to achieve Payment Integrity (PI)/FWA value creation and performance delivery

Collaborate with key stakeholders and leaders from PI teams and other CareSource departments to ensure their data needs are being met

Validate PI vendor deliverables, results and collaborate with PI vendors to understand and drive CareSource FWA analytic needs and results, act as consultant to propose business solutions, and communicate results of data analytics outcomes against goals and strategic plan

Work with subject matter experts to develop business rules that support data modeling and dashboard creation

Implement process improvement initiatives and automation for efficiency where appropriate both internally and externally with vendors

Support consistent interpretation of all policies of all analytics used in PI (FWAE) including vendors and prepare and monitor various management analytic dashboard and oversight metrics and reports as required

Lead and manage cross-functional reporting teams focused on identifying and building PI-related operational, market, and executive reports and dashboards

Consult with PI leadership to ensure appropriate metrics are in place to accurately measure the quality and effectiveness of their processes

Oversee and manage automated reporting that meets the decision support and business needs of each PI department lever (Pre-pay, Post-Pay, Education, SIU, Internal Controls)

Provide content expertise in RFI/RFP responses supporting new business opportunities

Formulate strategies and implements approach for new FWA schemes to identify and address FWA risks to members, health plans and the Company

Research and drive advocacy and awareness efforts for healthcare/Medicaid/Medicare FWA policy changes and impacts to existing and future analytic detection capabilities.

Monitor emerging internal and external FWA vulnerabilities and impacts to CareSource and create solutions to mitigate risk

Support analytic/data reporting needs and data interpretation consultation in collaboration with Investigators, Coders and Medical Directors

Provide leadership and direction over definition and development of PI reporting requirements

Create and drive departmental strategic planning, initiative prioritization and recommended action plans as they relate to Payment Integrity Ideation and Data Analytics

Proactively collaborate with key business owners within various business areas including finance, operations, clinical, and markets to establish partnerships and collaborate and communicate on Payment Integrity audits and impacts to providers

Identify savings initiatives that drive specific and measurable results, providing timely and meaningful client updates

Identify and quantify data integrity issues within PI and assist in the development of internal controls to resolve data issues

Establish strong relationships with internal and external stakeholders to define, align, and deliver payment integrity initiatives in support of assigned clients

Perform any other job-related instructions, as requested

Qualification

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Data VisualizationPower BIData AnalysisSQLHealthcare ManagementData ModelingMicrosoft OfficeStatistical MethodsCPT CodingICD10 CodingHCPCS CodingAPCDRGsSix SigmaHealthcare Fraud InvestigationProject Management

Required

Bachelor’s degree or equivalent relevant work experience is required

Minimum of seven (7) years of experience in data analysis to include five (3) years leading analytic teams is required

Extensive experience with Data Visualization / Dashboard tools (Power BI) required

Healthcare management and experience with Medicare/Medicaid required

Experience conducting analysis on large data sets and data modeling required

Advanced level experience in Microsoft Office products (Access, Excel, Visio and PowerPoint)

Proficiency in using SQL for analytics projects, including databases queries

Strong data analysis and trending skills and knowledge of statistical methods used in the evaluation of healthcare claims data

Strong understanding of healthcare payment methodologies, policies, and coding

Advanced knowledge of coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)

High level investigative experience

Excellent presentation and written and oral communication skills

Ability to communicate effectively with executive management and business community

Ability to think outside of the box and breakdown complex problems into individual root causes

Self-managed, self-starter with the ability to support multiple concurrent projects and meet tight deadlines

Proven results-oriented leadership and strategic management skills

Demonstrated critical listening and thinking skills

Excellent decision making/problem solving skills