Sr BI Analyst
About The Position
Blue Cross NC is seeking a Senior Business Intelligence Analyst to join the Medical Economics team, with a primary focus on Payment Integrity analytics. This role will be responsible for developing advanced analyses that identify cost leakage, inappropriate utilization, coding anomalies, and payment errors across medical and pharmacy claims. In this role you will combine your strong technical BI skills, deep healthcare claims knowledge, and your ability to translate complex findings into actionable insights for clinical, operations, and executive stakeholders. What You Will Do Payment Integrity & Medical Economics Analytics Lead end‑to-end analytical support for Payment Integrity programs, including: Pre‑pay and post‑pay claims reviews Coding intensity and DRG shift analysis E&M level distribution and complexity migration Quantify financial opportunity (PMPM and total impact) associated with PI findings and track realized savings. Partner with PI operations, SIU, RCM, and vendor teams to prioritize interventions based on economic value and feasibility. Data Analysis & BI Development Develop and maintain dashboards, reports, and analytical models using claims, eligibility, provider, and benchmark data. Perform trend analysis, benchmarking, and peer comparisons to identify outliers and emerging risk areas. Design repeatable, scalable analytical frameworks to support ongoing monitoring of PI performance. Stakeholder Engagement & Storytelling Translate analytical findings into clear, concise narratives for leadership, including Medical Economics, Finance, Network, and Clinical partners. Support executive‑level presentations with well‑structured insights, visuals, and recommendations. Serve as a thought partner to PI leadership in shaping strategy, measurement, and roadmap development. Data Governance & Quality Ensure analytical outputs are accurate, reproducible, and aligned with enterprise data definitions. Partner with data engineering and enterprise analytics teams to improve data availability, reliability, and performance. What You Bring • Bachelor's degree or advanced degree (where required) • 5+ years of experience in related field. • In lieu of degree, 7+ years of experience in related field. Strong working knowledge of medical claims data, including: CPT, HCPCS, ICD‑10, DRG, E&M coding Facility vs. professional claims Advanced proficiency in SQL and experience with large healthcare datasets. Strong experience with BI and visualization tools (e.g., Power BI, Tableau, Looker). Demonstrated ability to quantify cost of care and savings opportunities in PMPM and total dollars
Requirements
- Bachelor's degree or advanced degree (where required)
- 5+ years of experience in related field.
- In lieu of degree, 7+ years of experience in related field.
- Strong working knowledge of medical claims data, including: CPT, HCPCS, ICD‑10, DRG, E&M coding Facility vs. professional claims
- Advanced proficiency in SQL and experience with large healthcare datasets.
- Strong experience with BI and visualization tools (e.g., Power BI, Tableau, Looker).
- Demonstrated ability to quantify cost of care and savings opportunities in PMPM and total dollars
Nice To Haves
- Experience supporting Payment Integrity, FWA, or RCM functions at a health plan or payer‑focused consulting firm.
- Familiarity with external benchmarks (e.g., Milliman, BHI, CMS, HEDIS‑adjacent measures).
- Experience working with vendor‑based PI programs and validating vendor findings.
- Working knowledge of Python or R for advanced analytics (a plus).
- Prior experience in a Blue plan or large regional payer environment.
Responsibilities
- Lead end‑to-end analytical support for Payment Integrity programs, including: Pre‑pay and post‑pay claims reviews Coding intensity and DRG shift analysis E&M level distribution and complexity migration
- Quantify financial opportunity (PMPM and total impact) associated with PI findings and track realized savings.
- Partner with PI operations, SIU, RCM, and vendor teams to prioritize interventions based on economic value and feasibility.
- Develop and maintain dashboards, reports, and analytical models using claims, eligibility, provider, and benchmark data.
- Perform trend analysis, benchmarking, and peer comparisons to identify outliers and emerging risk areas.
- Design repeatable, scalable analytical frameworks to support ongoing monitoring of PI performance.
- Translate analytical findings into clear, concise narratives for leadership, including Medical Economics, Finance, Network, and Clinical partners.
- Support executive‑level presentations with well‑structured insights, visuals, and recommendations.
- Serve as a thought partner to PI leadership in shaping strategy, measurement, and roadmap development.
- Ensure analytical outputs are accurate, reproducible, and aligned with enterprise data definitions.
- Partner with data engineering and enterprise analytics teams to improve data availability, reliability, and performance.
Benefits
- Annual Incentive Bonus
- 401(k) with employer match
- Paid Time Off (PTO)
- competitive health benefits and wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
