Healthcare Data Analyst

Provides data & informatics support and analyses including quality matrices, outcomes studies and program evaluations, internal and external reporting, monitoring data trends and identifying patterns, performing modeling, recommending improvement solutions.

  • Detailed knowledge of health care claiming rules for both medical and pharmacy and familiarity with both the requirements for and data on health care claiming forms
  • An understanding of third-party adjudication process
  • Ability to independently research and interpret claiming regulations and rules at both Federal and local level
  • Ability to identify potential overpayment scenarios in the payment of medical and pharmacy claims. Individual will also design and conduct the data analyses required to support the identified overpayments.
  • Monitor data trends, perform statistical analyses and prepare reports to facilitate Centers for Medicare and Medicaid Services (CMS) contract requirements.
  • Experience in applying Correct Coding Initiative (CCI) or Outpatient Code Editor (OCE) or Medically Unlikely (MUE) edit a plus
  • Experience with manipulating and analyzing large datasets.
  • Ability to prepare Medical Loss Ratio Reports for multiple contracts.
  • Provide subject matter expertise on analyzing, vetting, and understanding healthcare data.
  • Develop and deploy analysis methods for detecting healthcare waste, fraud, and abuse
  • Form and support robust opinions with imperfect data while still revising your beliefs in the face of compelling new data or analyses
  • Actively review and suggest improvements to current or planned systems and processes based on your knowledge of healthcare claims data
  • Collaborates with clients, development team and product management on a regular basis.

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Required Education and Experience

  • Bachelors or Masters degree in related field
  • 3 years of experience with analyzing healthcare data – this experience should include work in at least 2 of the following areas:
  • Fee-for-Service claims analysis
  • Encounter claims analysis
  • Enrollment
  • Medicare crossover claims
  • MCO, federal, or other state Medicaid data
  • HEDIS Rate Calculation/Score Improvement
  • Testifying to, vetting, or certifying data analyses for use in litigation or policymaking
  • Proficiency in at least one statistical analysis, scripting, or programming language (R, PHP, Java, Python, Matlab, SAS, etc) or expertise in relevant tool (Excel, Business Objects, Access) required.
  • SQL proficiency required.
  • Well versed in healthcare compliance and HIPAA
  • HEDIS Experience Preferred
  • Expert knowledge of state and federal laws and regulations pertaining to Medicaid
  • Demonstrated communication and presentation skills
  • Applicant may be subject to a government security clearance investigation
  • At least two years prior experience in health care claiming field, either with a provider of medical or pharmacy services or at a payer for health care claims, including a state Medicaid Management Information System (MMIS) or as a consultant to either providers or payers.
  • Technical skills will include, but are not limited to: SQL, SAS, Excel, Access
  • Intermediate level of proficiency in Microsoft Office software application including Word, Excel, and Powerpoint
  • Ability to manage multiple projects simultaneously
  • Detail oriented with excellent communication skills (oral presentations and written) and interpersonal skills
  • Must be curious, passionate, skeptical, and determined to get to the core of difficult problems
  • Self-starter, able to independently identify and complete critical tasks with minimal supervision, messy data, and dynamic goals

Supervisory Responsibilities

Not applicable to this position.

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