This position is responsible for the analysis of claims billing and payment data to support the Enterprise Investigative Services and Provider Audit departments as well as departmental productivity and needs analysis . That analysis requires the use of statistical and other analytical software applications and development of models and reports using those applications. The incumbent must maintain a strong awareness and vision for providing automated system solutions and data analyses to the Enterprise Investigative Services and Provider Audit departments. This position will lead the development of analyses that support assessment of referrals for audit purposes and for case development.
Job Duties & Responsibilities
Develop analytical models to support the EIS and Provider Audit departments in their reviews of claims across all lines of business (Commercial, FEP, ITS, BlueCare).
Develop reports for Provider Audit productivity and needs analysis
Analyze and provide reports on claims data in the corporate data warehouse to provide statistical and financial information for decision-making and determination of focus for audits and investigations.
Provide input to management in the evaluation of Enterprise Investigative Services and Provider Audit technology needs and for the long-term solutions that support the integration of those departments’ activities.
Continually analyze and identify areas for improvement in data analysis methods and processes sharing discoveries with management and others as is appropriate.
Maintain expertise with data extraction tools, data validation and turning data into information that will be used in the development and production of reports for use in audits and legal cases.
Serve as back-up when necessary by:
Being a liaison with Information Security, Network Services, Information Systems and fraud detection software vendors
Supporting the technical needs of the Enterprise Investigative Services and Provider Audit staffs on an as-needed basis
Providing required reports to BCBSA, state and federal governments and self-funded accounts.
Interfacing with outside agencies and organizations regarding data analysis, criminal/civil litigation case file preparation and data acquisition.
Participating in multidisciplinary committees and workgroups.
Bachelor’s Degree in related field or equivalent years of experience. Equivalent years of experience are defined as a year of professional experience for every year of college requested.
Minimum of 3 years data mining and analysis required, with 3 years of SAS preferred.
Ability to build and maintain complex and efficient data extraction, manipulation, querying and reporting processes using such tools as Cognos, MS Access, SQL, QMF, SAS, , etc. required.
Solid understanding of coding, audit, and contracting areas highly preferred.
Extensive experience with BCBST’s Data Warehouse or other healthcare data is preferred.
Extensive technical skills in data mining and modeling to effectively utilize extensive volumes of corporate data in conjunction with the complex local database that supports multiple departments.
Exceptional analytic, problem-solving and critical thinking skills.
The incumbent must understand the interrelationships of benefit design, group and member contracts, provider contracts and reimbursement models. Solid practical knowledge of the corporate data warehouse structure is imperative. The individual must be independent and self-motivated.
Excellent communication skills, both verbal and written are essential.
Ability and willingness to testify in court as an expert witness regarding data, access methods, analysis methods and tools used by Enterprise Investigative Services, Provider Audit and BCBST as needed.
BlueCross BlueShield of Tennessee - 2 years ago
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....