Program Integrity Rptg Analyst

Amerihealth Caritas•,

2d•Hybrid

About The Position

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Your career starts now. We’re looking for the next generation of health care leaders. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Requirements

Bachelor’s Degree required.
Minimum 3 to 5 years data analysis and reporting experience required.
Minimum 3 years of SQL, SAS Enterprise Guide (EG), MS Access, MS Excel, Tableau.
Experience with other MS applications, such as PowerPoint and Visio preferred.
Experience in creating, supporting or writing reports, business correspondence and technical documents required.
Knowledge of claims processing.
Experience gathering requirements and documenting specifications required.
Experience in driving projects from initiation through to completion, and in being an accountable party for results.
Experience working in a team setting and on assigned project teams as required.
Excellent verbal and written communication skills.
Strong analytical, conceptual and problem-solving skills to evaluate complex business reporting requirements and to translate these into value-added solutions.
Proven ability to manage multiple concurrent tasks/projects.
Strong work ethic, self-motivated, self-initiated learner.

Nice To Haves

Experience with other MS applications, such as PowerPoint and Visio.
SQL, SAS Enterprise Guide (EG), Facets, MS Access, MS Excel, Tableau with experience with other MS applications, such as PowerPoint and Visio preferred.

Responsibilities

Performs research and creates reports to monitor for progress of cases in assigned lines of business.
Manages fraud, waste and abuse (FWA) case activity through regulatory reporting of assigned lines of business weekly/monthly/quarterly/annually in addition to ad hoc requests.
Identifies systemic issues of FWA.
Initiates the request and follow-up to reprocess claims as a result of FWA audits and investigations.
Provides claims processing technical support/expertise to team members.
Audits claims for correct coding issues and identify potential recoveries or processing errors.
Maintains the FWA claim inventory and provides weekly reports.
Ensures for timely and accurate transfer of claims and accompanying claims issues from the Special Investigation Unit (SIU) to the Operations/Cost Containment Department and monitoring until the claims reach their final disposition.
Collaborates with Manager, Data Analytics Manager, PI Associates, including the Special Investigations Unit as well as associates at all levels of the organization, as required, to define reporting objectives and implement meaningful, effective, efficient, repeatable, and scalable solutions.
Updates the SIU case tracking system with progress and follow-up actions, including required reporting associated with such.
Extracts and summarizes data from a variety of systems, including Facets, other SIU systems, data warehouses and other available databases.
Formats reports into visually effective tools, incorporating as appropriate graphs, charts, etc.
Prepares clear, accurate, timely and informative statistical and narrative reports containing findings, analysis, conclusions, and recommendations.
Continuously analyzes existing PI reports, making recommendations for enhancements to same.
Ensures incoming report requests adhere to submission requirements and are maintained in the report request database.
Defines, documents and maintains report requirements, development methodology and essential reporting records for all reports developed and or enhanced.
Analyzes data and reporting aberrations and provide written explanations for variances and recommended changes.
Researches, tests and validates all data results for accuracy and completeness before distributing scheduled and ad-hoc reports.
Ensures all reports can be shared with/distributed to other Associates without jeopardizing data integrity of same.
Maintains library of available PI reports, as well as an archive for historical reports and their associated distribution lists.