Conducts analysis of claims and payment data across CHOICE health plans in support of ensuring payment integrity and cost containment. Identifies anomalous utilization patterns, investigates cost containment, and tests alignment with vendors contracted rates. Reconciles and validates underlying analytic data claims, and utilization management systems. Tests the integrity of utilization and payment data across plans and functions. Engages in activities to support corrective actions to functions, CHOICE Operations and Compliance as directed. Works under general supervision.
- Assists the Manager in analyzing and validating managed care claims and comp grids against provider contracts, member eligibility, benefit grids, and authorization data to ensure VNSNY CHOICE pays our Providers appropriately and VNSNY CHOICE contains cost.
- Investigates utilization and claims coding patterns to identify potential fraud, waste or abuse and coordinates with Compliance and Special Investigation Unit for recoveries as necessary.
- Analyzes affordability of medical cost against premium revenue for membership panels of providers, in specific settings, or across other attribution categories as appropriate.
- Communicates with internal departments (i.e. Claims, Providers, Finance etc) to validate existence of integrity leakage points, and coordinates to develop and implement corrective solutions and recovery.
- Attends meetings with analytics teams, product teams, operations, and allied departments to communicate status of investigative projects and identify new areas of opportunity or priorities. Keeps management informed as necessary.
- Utilizes CHOICE analytic data warehouse and native claims systems and other supporting data for investigation.
- Validates accuracy, timeliness, and performance of claims processing vendor as directed
- Conducts analysis of delegated vendor claims data to test affordability, support contract negotiations, and identify potential errors or Fraud, Waste, and Abuse for further investigation by Special Investigation Unit Compliance, or other departments.
- Assists encounter team in ensuring alignment of claims to encounters.
Education: Bachelors degree required preferably in Technology, Information Science, Mathematics or statistics.
Experience: Minimum of three years managed care claims analysis experience required. Experience in financial or operational analytics preferred. Knowledge of Medicare and NYS Medicaid claims processing rules and coding experience with DRG, ICD10 and CPT4 required. Proficiency in standard business applications such as Microsoft Office required. Proficiency in claims processing platforms such as FACETS required. Proficiency in data analysis software such as SAS, R, or Stata preferred. Proficiency with SQL preferred. Excellent communication and analytical skills required.