FWA Payment Integrity Data Analyst III, Health Plan, SQL

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead and execute data analytic ideation and research-and-development initiatives that support decision-making across various business lines and clients.

• Validate deliverables and outcomes from Program Integrity vendors.

• Work in collaboration with Program Integrity vendors to comprehend and address FWA analytic needs and results.

• Suggest business solutions and communicate data analytics results in relation to goals and strategic plans.

• Engage in analytical, experimental, investigative, and fact-finding activities that support concept development and collaboration with vendors.

• Keep track of emerging internal and external FWA data vulnerabilities and trends, creating solutions for risk mitigation.

• Identify trends and patterns using corporate processes, tools, reports, databases, and various data sources.

• Research policies, coding guidelines, and regulations that underpin analytical hypotheses.

• Conduct outcome analyses to evaluate the impact and effectiveness of corporate and SIU initiatives.

• Analyze and clarify complex data relationships linked to Fraud, Waste, and Abuse.

• Create graphics that describe, explore, and summarize analyses.

• Oversee processes and reporting to ensure that investigation-related claims are processed accurately and promptly.

• Collaborate with the Legal Department by providing data and analyses that support legal proceedings.

• Carry out data analyses that support SIU Program Integrity and Audit Functions.

• Utilize critical thinking and judgment to determine the most appropriate course of action for each inquiry or issue.

• Review reports and data to detect patterns, special-cause variation, trends, and associative or causal relationships concerning Fraud, Waste, Abuse, and Errors.

• Deliver management-level summaries that elucidate key findings and documentation for audits.

• Employ descriptive statistics, sampling, and hypothesis testing to ascertain outcomes.

• Execute other job-related duties as assigned.

⛳️ Requirements

• A Bachelor's degree or equivalent relevant work experience in Healthcare Data Analytics is required.

• Seven (7) years of experience in data analysis, FWA Ideation, and/or analytic programming is required.

• Seven (7) years of experience in healthcare delivery and/or payer settings is required.

• Extensive proficiency with Data Visualization/Dashboard tools (Power BI) is required.

• Extensive experience utilizing SQL for analytics projects, including database queries, is required.

• Three (3) years of experience with Medicare/Medicaid is required.

• Experience/exposure in healthcare management is required.

• Clinical experience is preferred.

• Demonstrated understanding of database development, including relationships, data integration, SQL data manipulation, object creation, normalization, and dimensional design concepts.

• Knowledge in administering Microsoft SQL Server, Transact-SQL (ANSI-SQL), and Integration Services (SSIS) is required.

• Familiarity with programming languages such as Microsoft Visual Basic and Python is required.

• Strong understanding of coding standards, billing regulations, and procedure/diagnosis codes (CPT, ICD10, HCPCS, APC, and DRGs).

• Proven analytical skills in resolving multi-dimensional problems.

• Advanced proficiency in Microsoft Excel, Access, Word, and PowerPoint.

• Skills in SAS and SQL.

• Competence in graphic development and presentation.

• Knowledge of inferential statistics.

• Working knowledge of applications and techniques for descriptive statistics.

• Data mapping capabilities.

• Ability to document database and application design effectively.

• Ability to maintain documentation of changes and modifications.

• Strong critical listening, thinking, verbal, and written communication skills.

• Decision-making and critical-thinking capabilities.

• Ability to operate independently as well as within a team setting.

• Knowledge of Medicaid, Medicare, and managed care.

• Capacity to lead analytic initiatives.

• Coding certification from AAPC or AHIMA is preferred.

🏝️ Benefits

• Bonus opportunities tied to both company and individual performance may be available.

• A comprehensive total rewards package.

• Support for employee total well-being.