Healthcare Analytics – Payor/Provider Finance Data and AI, Managed Care Contracting & Optimization

Guidehouse•Chicago, IL

2d•$102,000 - $170,000

About The Position

The Healthcare Finance Data and AI team translates healthcare data into measurable healthcare financial performance. This role is dedicated to managed care contracting – you will learn to read payer contracts (commercial and government), model reimbursement terms in our existing tools, and enhance those tools with automation using SQL and Python. You will partner with contracting, revenue integrity, and patient financial services teams to ensure our modeled rates and rules align with contract language and adjudication behavior, and you will turn findings into clear, executive-ready recommendations. Learn and interpret payer contracts (fee schedules, DRG/APC, per diem, percent-of-charge, case rates, carveouts, stoploss/outlier, multiple procedure reductions, modifiers, bundling/packaging rules, lesser-of logic, escalators, effective dates, term/renewal, amendments). Translate contract terms into machine-readable logic and configure/model those terms in our existing pricing/adjudication tools. Validate modeled results by reconciling remittance advice (835/ERA) and historical payments; investigate and resolve discrepancies with root cause analysis. Maintain a controlled library of contract models (versioning, effective/expiry dates, audit trail, documentation of assumptions). Build/optimize ETL/ELT pipelines to ingest fee schedules and contract artifacts; implement QA/validation checks (e.g., dimensional completeness, rate reasonableness, variance thresholds). Use advanced SQL (window functions, CTEs, stored procedures, query tuning) to automate contract lookups, grouper logic, case mix normalization, and variance analytics. Use Python (preferred) for parsing artifacts, applying calculation engines, regression/variance checks, and generating repeatable validation reports. Develop Power BI/Tableau dashboards for contract performance (e.g., allowed vs. expected, underpayment/overpayment detection, denial patterns, yield by payer/product). Own analytics workstreams; present findings that connect contract mechanics to RCM KPIs (denial rate, DNFB, AR days, first pass yield, cash acceleration, net revenue). Work with Managed Care/Finance, Revenue Integrity/CDM, PFS, and IT/Data teams to align interpretation, data sources, and operationalization. Support pursuits (POVs, demos) showcasing our contract modeling capabilities and automation. Enhance our contract modeling tooling: propose schema/logic improvements, performance tuning, error handling, and test harnesses. Contribute reusable assets (SQL/Python modules, validation checklists, samples, documentation); uphold SDLC/Agile practices and code review standards.

Requirements

Bachelor's degree is required
Minimum THREE (3) years of experience in healthcare analytics, consulting, or adjacent healthcare services with measurable data driven outcomes (revenue cycle management exposure strongly preferred).
Experience building production-grade ETL/ELT processes and implementing data quality frameworks.
Proficiency with BI/visualization tools (Power BI or Tableau) and strong Excel skills.
Excellent communication—able to translate technical and contractual details into concise, executive-ready insights.
Detail oriented, self-directed, collaborative teammate comfortable leading workstreams.

Nice To Haves

Hands‑on with Azure Data Factory, Databricks, SSIS (or similar).
Understanding of payer/provider operations and payment methodologies; experience with contract modeling or payment variance analytics is a strong plus (we will train on contract reading).
Experience with Agile practices and Git-based version control.
Experience with regulatory reporting and transparency initiatives (e.g., CMS price transparency, charge master reviews).

Responsibilities

Learn and interpret payer contracts (fee schedules, DRG/APC, per diem, percent-of-charge, case rates, carveouts, stoploss/outlier, multiple procedure reductions, modifiers, bundling/packaging rules, lesser-of logic, escalators, effective dates, term/renewal, amendments).
Translate contract terms into machine-readable logic and configure/model those terms in our existing pricing/adjudication tools.
Validate modeled results by reconciling remittance advice (835/ERA) and historical payments; investigate and resolve discrepancies with root cause analysis.
Maintain a controlled library of contract models (versioning, effective/expiry dates, audit trail, documentation of assumptions).
Build/optimize ETL/ELT pipelines to ingest fee schedules and contract artifacts; implement QA/validation checks (e.g., dimensional completeness, rate reasonableness, variance thresholds).
Use advanced SQL (window functions, CTEs, stored procedures, query tuning) to automate contract lookups, grouper logic, case mix normalization, and variance analytics.
Use Python (preferred) for parsing artifacts, applying calculation engines, regression/variance checks, and generating repeatable validation reports.
Develop Power BI/Tableau dashboards for contract performance (e.g., allowed vs. expected, underpayment/overpayment detection, denial patterns, yield by payer/product).
Own analytics workstreams; present findings that connect contract mechanics to RCM KPIs (denial rate, DNFB, AR days, first pass yield, cash acceleration, net revenue).
Work with Managed Care/Finance, Revenue Integrity/CDM, PFS, and IT/Data teams to align interpretation, data sources, and operationalization.
Support pursuits (POVs, demos) showcasing our contract modeling capabilities and automation.
Enhance our contract modeling tooling: propose schema/logic improvements, performance tuning, error handling, and test harnesses.
Contribute reusable assets (SQL/Python modules, validation checklists, samples, documentation); uphold SDLC/Agile practices and code review standards.

Benefits

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave and Adoption Assistance
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Student Loan PayDown
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program
Mobility Stipend