Job Summary:
The Senior Manager, Payment Integrity Data Analytics is responsible for leading the creation, scoping, planning, prioritizing, and managing of all Payment Integrity predictive analytic projects, vendor management/integration of analytic ideation and deployment for Program Integrity.
Essential Functions:
- Develop and execute Analytic/Ideation and vendor analytic strategy to achieve Payment Integrity (PI)/FWA value creation and performance delivery
- Collaborate with key stakeholders and leaders from PI teams and other CareSource departments to ensure their data needs are being met
- Validate PI vendor deliverables, results and collaborate with PI vendors to understand and drive CareSource FWA analytic needs and results, act as consultant to propose business solutions, and communicate results of data analytics outcomes against goals and strategic plan
- Work with subject matter experts to develop business rules that support data modeling and dashboard creation
- Implement process improvement initiatives and automation for efficiency where appropriate both internally and externally with vendors
- Support consistent interpretation of all policies of all analytics used in PI (FWAE) including vendors and prepare and monitor various management analytic dashboard and oversight metrics and reports as required
- Lead and manage cross-functional reporting teams focused on identifying and building PI- related operational, market, and executive reports and dashboards
- Consult with PI leadership to ensure appropriate metrics are in place to accurately measure the quality and effectiveness of their processes
- Oversee and manage automated reporting that meets the decision support and business needs of each PI department lever (Pre-pay, Post-Pay, Education, SIU, Internal Controls)
- Provide content expertise in RFI/RFP responses supporting new business opportunities
- Formulate strategies and implements approach for new FWA schemes to identify and address FWA risks to members, health plans and the Company
- Research and drive advocacy and awareness efforts for healthcare/Medicaid/Medicare FWA policy changes and impacts to existing and future analytic detection capabilities.
- Monitor emerging internal and external FWA vulnerabilities and impacts to CareSource and create solutions to mitigate risk
- Support analytic/data reporting needs and data interpretation consultation in collaboration with Investigators, Coders and Medical Directors
- Provide leadership and direction over definition and development of PI reporting requirements
- Create and drive departmental strategic planning, initiative prioritization and recommended action plans as they relate to Payment Integrity Ideation and Data Analytics
- Proactively collaborate with key business owners within various business areas including finance, operations, clinical, and markets to establish partnerships and collaborate and communicate on Payment Integrity audits and impacts to providers
- Identify savings initiatives that drive specific and measurable results, providing timely and meaningful client updates
- Identify and quantify data integrity issues within PI and assist in the development of internal controls to resolve data issues
- Establish strong relationships with internal and external stakeholders to define, align, and deliver payment integrity initiatives in support of assigned clients
- Perform any other job-related instructions, as requested
Education and Experience:
- Bachelor’s degree or equivalent relevant work experience is required
- Master’s degree or equivalent years of relevant work experience preferred
- Minimum of seven (7) years of experience in data analysis to include five (3) years leading analytic teams is required
- Extensive experience with Data Visualization / Dashboard tools (Power BI) required
- Healthcare management and experience with Medicare/Medicaid required
- Experience conducting analysis on large data sets and data modeling required
Competencies, Knowledge and Skills:
- Advanced level experience in Microsoft Office products (Access, Excel, Visio and PowerPoint)
- Proficiency in using SQL for analytics projects, including databases queries
- Strong data analysis and trending skills and knowledge of statistical methods used in the evaluation of healthcare claims data
- Strong understanding of healthcare payment methodologies, policies, and coding
- Advanced knowledge of coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)
- Knowledge of medical insurance and/or state regulatory requirements desirable
- High level investigative experience
- Excellent presentation and written and oral communication skills
- Ability to communicate effectively with executive management and business community
- Ability to think outside of the box and breakdown complex problems into individual root causes
- Self-managed, self-starter with the ability to support multiple concurrent projects and meet tight deadlines
- Proven results-oriented leadership and strategic management skills
- Demonstrated critical listening and thinking skills
- Excellent decision making/problem solving skills
Licensure and Certification:
- SQL Server, SAS, or Power BI certification is preferred
- Project Manager Professional (PMP), Six Sigma, or similar professional certification is a plus
- AAPC, AHIMA, NICB, IASIU, ACFE, or NHCAA certificates or training in healthcare fraud and abuse investigations, preferred but not required
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$90,500.00 - $158,400.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
