Job Summary:

The FWA Payment Integrity Data Analyst III is responsible for developing, implementing, managing and presenting in-depth analyses that meet the information needs associated with Fraud, Waste and Abuse.

Essential Functions:

• Lead and implement data analytic Ideation and R&D activities and strategy to support decision-making across multiple lines of business and clients to enable FWA growth.
• Validate Program Integrity vendor deliverables, results and collaborate with PI vendors to understand and drive CareSource FWA analytic needs and results, function as consultant to propose business solutions, and communicate results of data analytics outcomes against goals and strategic plan.
• Participate in analytical, experimental, investigative, and other fact-finding work in support of concept development and in conjunction with vendors.
• Monitor emerging internal and external FWAE data vulnerabilities and trends which may impact CareSource and create solutions to mitigate risk.
• Identify trends and patterns using standard corporate, processes, tools, reports, and databases as well as leveraging other processes and data sources
• Research policies, coding guidelines, and regulations that would support the hypothesis being developed.
• Conduct outcome analyses to determine impact and effectiveness of corporate and SIU initiatives.
• Collaborate on the examination and explanation of complex data relationships to answer questions identified either within the department or by other departments as it relates to Fraud Waste and Abuse.
• Generate graphics that effectively describe, explore, and summarize analysis for communication to appropriate parties.
• Manage processes and reporting to ensure that claims associated with investigations are processed appropriately and in a timely manner.
• Collaborate with the Legal Department, generating data and analyses to support Legal proceedings.
• Perform data analyses in support of both the SIU Program Integrity and Audit Functions.
• Incorporate critical thinking skills and judgment in the analysis process to determine best course of action for each inquiry/problem.
• Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques that will reveal intelligence for identification of any associative or causal relationships pertaining to Fraud Waste and Abuse and Error, providing management level summaries that explain key findings and providing documentation for use during Audits.
• Use descriptive statistical techniques to measure impact of various actions/studies, internal and external, develop sampling and hypothesis testing to help the organization determine outcomes.
• Performs any other job related duties as requested.

Education and Experience:

• Bachelor's degree or equivalent years of relevant work experience in Healthcare Data Analytics required
• Seven (7) years of experience in data analysis, FWA Ideation and/or analytic programming required
• Seven (7) years Health care delivery and/or payer experience required
• Extensive experience with Data Visualization / Dashboard tools (Power BI) required
• Extensive experience using SQL for analytics projects, including databases queries required
• Three (3) years of experience with Medicare/Medicaid required
• Healthcare management experience/exposure required
• Clinical experience is preferred

Competencies, Knowledge and Skills:

• Proven understanding of database development including: Implementing Database Relationships; Data Integration; Data Manipulation using SQL; Database Object Creation using SQA; Database Normalization; Dimensional Design Concepts
• Insight in administering Microsoft SQL Server, Transact-SQL (ANSI-SQL) and Integration Services (SSIS) is required
• Insight and understanding of in programming languages such as Microsoft Visual Basic, Python
• Strong Knowledge of coding standards, billing rules and regulations and knowledge of procedure and diagnosis codes (CPT, ICD10 coding, HCPCS, APC and DRGs)
• Proven analytic skills in solving multi-dimensional problems
• Advanced level experience in Microsoft Applications: Excel, Access, Word, and PowerPoint
• SAS and SQL skills
• Graphic development/presentation skills
• Knowledge of inferential statistics
• Working knowledge of descriptive statistical application and techniques
• Data Mapping Skills
• Ability to document database design, application design
• Ability to maintain documentation of changes and modifications
• Critical listening, thinking skills, and verbal and written communication skills
• Decision making/critical thinking skills
• Ability to work independently and within a team environment
• Knowledge of Medicaid, Medicare, and managed care
• Ability to lead analytic efforts

Licensure and Certification:

• Coding certification through AAPC or AHIMA preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

Compensation Range:

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. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

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 environment of belonging that welcomes and supports individuals of all backgrounds.