FWA Payment Integrity Data Analyst III (Health Plan & SQL exp required)
About The Position
The FWA Payment Integrity Data Analyst III develops, implements, manages, and presents in-depth analyses to meet information needs related to Fraud, Waste, and Abuse (FWA). The role leads analytical ideation and research and development activities supporting decisions across multiple lines of business and clients, validates Program Integrity vendor deliverables, and works with vendors to identify and address analytic needs. It also monitors emerging data vulnerabilities and trends, researches relevant policies and regulations, and evaluates the effectiveness of corporate and Special Investigations Unit (SIU) initiatives. The analyst examines complex data relationships, identifies patterns and trends, develops visual presentations of findings, and provides management-level summaries and audit documentation. The role supports SIU Program Integrity and Audit functions, Legal proceedings, and the appropriate and timely processing of claims associated with investigations. Work involves applying statistical techniques, critical thinking, and judgment to determine appropriate actions and communicate analytical results.
Requirements
- Bachelor's degree or equivalent years of relevant work experience in healthcare data analytics.
- Seven years of experience in data analysis, FWA ideation, and/or analytic programming.
- Seven years of healthcare delivery and/or payer experience.
- Extensive experience with data visualization and dashboard tools, including Power BI.
- Extensive experience using SQL for analytics projects, including database queries.
- Three years of experience with Medicare and/or Medicaid.
- Healthcare management experience or exposure.
- Understanding of database development, including database relationships, data integration, SQL data manipulation, database object creation using SQA, database normalization, and dimensional design concepts.
- Knowledge of administering Microsoft SQL Server, Transact-SQL (ANSI-SQL), and Integration Services (SSIS).
- Knowledge of programming languages such as Microsoft Visual Basic and Python.
- Knowledge of coding standards, billing rules and regulations, and procedure and diagnosis codes, including CPT, ICD-10, HCPCS, APC, and DRGs.
- Analytical skills to solve multidimensional problems.
- Advanced experience with Microsoft Excel, Access, Word, and PowerPoint.
- SAS and SQL skills.
- Graphic development and presentation skills.
- Knowledge of inferential statistics and working knowledge of descriptive statistical applications and techniques.
- Data mapping skills.
- Ability to document database and application design and maintain documentation of changes and modifications.
- Critical listening, thinking, decision-making, verbal communication, and written communication skills.
- Ability to work independently and within a team environment.
- Knowledge of Medicaid, Medicare, and managed care.
- Ability to lead analytical efforts.
Nice To Haves
- Clinical experience.
- Coding certification through AAPC or AHIMA.
Responsibilities
- Lead and implement data analytic ideation, research and development activities, and strategy to support decision-making across multiple lines of business and clients.
- Validate Program Integrity vendor deliverables and results, collaborate with vendors on FWA analytic needs, propose business solutions, and communicate analytical outcomes against goals and strategic plans.
- Participate in analytical, experimental, investigative, and fact-finding work in support of concept development and vendor work.
- Monitor emerging internal and external FWA data vulnerabilities and trends and develop solutions to mitigate risk.
- Identify trends and patterns using corporate processes, tools, reports, databases, and other processes and data sources.
- Research policies, coding guidelines, and regulations that support analytical hypotheses.
- Conduct outcome analyses to determine the impact and effectiveness of corporate and SIU initiatives.
- Collaborate on examining and explaining complex data relationships to answer FWA-related questions from within or outside the department.
- Generate graphics that describe, explore, and summarize analyses for appropriate audiences.
- Manage processes and reporting to ensure claims associated with investigations are processed appropriately and in a timely manner.
- Collaborate with the Legal Department by generating data and analyses to support 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 FWA and errors; provide management-level summaries and audit documentation.
- Use descriptive statistical techniques to measure the impact of actions and studies, and develop sampling and hypothesis testing to help determine outcomes.
- Perform other job-related duties as requested.
Benefits
- May qualify for a bonus tied to company and individual performance.
- Substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
