Analyst - Senior - Payment Integrity Unit

Responsible for leading the development and implementation of programs and strategies by identifying insights that enhance business decision making capability. This includes developing or changing workflows and implementing process improvements to enhance organizational products, programs and service to our customers. * Identify and analyze operational data and develop insights in support of business objectives. * Develop and improve work flows and business processes within defined areas to improve customer service, decrease operational costs and improve overall quality. * Identify and/or analyze business problems and develop recommendations for solutions to problems. * Lead the development and implementation of projects and/or teams in order to produce desired results. * Document and communicate project concepts, milestones and results. * Recommend and assist with implementing standard policies and procedures. * Ensure that corporate compliance is communicated, implemented and monitored on an ongoing basis. * Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process. * Provide support to internal departments and external entities by answering questions, supplying information and training. * Create and present reports and presentations to display operational data and proposed business changes. Qualifications * Bachelor's Degree in a related field is preferred. * Four (4) years of experience in a related field is required. * Excellent analytical and problem-solving skills to identify, evaluate, recommend and implement changes to processes or procedures to address problems and improve departmental effectiveness. * Organizational skills and ability to prioritize; must be able to lead multiple activities with varying timelines. * Excellent verbal, written communication and interpersonal skills. * Ability to lead and contribute to business unit and/or corporate projects. * Proficient in Microsoft Office Suites. * Ability to develop and maintain effective working relationships. Departmental Preferences: * Designs, develops, and documents objective approaches to investigate, analyze, and pursue claims overpayment hypotheses. * Knowledge of Blue Care Network Commercial & Medicare Advantage plan operations. * Strong working knowledge of claims operations, including knowledge of coordination of benefits (COB), claims process flows for medical/surgical, DME, and pharmaceutical vendors. * Knowledge of related laws, legal codes, government regulations, and applicable CMS policy. * Ability to work with mathematical concepts such as probability and statistical inference, fractions, percentages, ratios, and proportions to practical situations. * Ability to define problems, collect data, establish facts, and draw valid conclusions. All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

Created: 2024-11-12