Claims Reporting/Data Analyst

Commonwealth Care Alliance-posted 3 months ago
Remote • Boston, MA
Ambulatory Health Care Services
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This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time. Working under the direction of the SVP Claims, the Senior Data Analyst - Payment Integrity & Claims will provide routine and ad hoc analytics to drive impactful material, recommendations, and data driven decision making to support overall payment integrity and claim operations discussions and strategic partnerships. This role will develop tools and reporting infrastructure to monitor overall performance, key performance indicators, and vendor performance associated with Service Level Agreements to support organizational decision-making, and identify opportunities to improve quality and control costs.

  • Using Excel, SQL, Access, Tableau and/or other data analysis tools, develop analyses and reports to support CCA decision making related to provider contracting
  • Develop ad hoc analyses of varying levels of complexity to support claim query requests, claim retraction valuation and viability, support payment policies, support audit requests, assist in the development of a claim audit repository for tracking and develop robust reporting and dashboards.
  • Produce provider scorecards related to Payment Integrity initiatives and lead internal and external provider meetings to review results and trends.
  • Synthesize information into impactful materials and presentations to facilitate recommendations to leadership and Executive Teams.
  • Conduct independent research and analysis using regulatory guidance, government data and statistics, reports, publications, and other publicly available data sources to inform network development activities and decision-making.
  • Develop methodologies and infrastructure to measure the impact of executed initiatives.
  • Develops and maintains the production of performance reports and standard KPI reports to monitor and report on overall department metrics, program evaluation, and SLA performance.
  • Lead and support cross-functional initiatives to enhance analytical infrastructure necessary to support network development goals.
  • Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of quality-improvement and cost-savings initiatives.
  • Collaborates with and builds strong partnerships across the organization to align network recruitment and management activities with membership and clinical care goals, regulatory compliance, and other organizational priorities.
  • Possesses a strong background in data analysis, health care reimbursement, financial analyses, provider contracting, and a broad range of provider reimbursement methodologies.
  • Strong communication skills to translate data and analytical results into actionable information.
  • Actively participates in the evaluation of own performance.
  • Understand and track vendor data including KPIs associated with SLAs, invoice validation/reconciliation, and valuations.
  • Bachelor's Degree or Equivalent experience
  • 3-5 years Data Analysis
  • 3+ years of Healthcare experience
  • 3+ SQL
  • Strong analytical skills and familiarity with common data analytics tools, including Excel, Access, SQL, Tableau or other analytical tools
  • Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)
  • Ability to work cross functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives
  • Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks
  • Ability to identify, develop, track, and measure key performance metrics
  • Ability to develop and conceptualize data in a way that can be presented to senior leadership for decision making
  • Ability to understand and analyze data as a measurement against KPIs
  • Comfort working and communicating using data
  • Ability to communicate and work effectively at multiple levels within the company
  • Customer service orientation; positive outlook, self-motivated and able to motivate others
  • Strong work ethic; able to solve problems and overcome challenges
  • Masters Degree
  • Experience with core claims platforms - Facets, QNXT, or Amisys
  • MS, HTML, other software and tools
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