Provide strategic analysis that influences business decisions, improves efficiency and drives innovation. Extract and aggregate claims data from various sources. Execute complex claims data analysis that guide the detection, prevention and deterrence of fraud, waste and abuse; and that guide the development of medical coverage guidelines, reimbursement policies, risk assessments and other medical cost containment solutions. Prepare summary findings and recommendations into investigative reports
Identify, analyze, interpret and validate healthcare data metrics, fraud, waste and abuse trends and patterns
Provide accurate, timely and reliable delivery of data, metrics, reporting and analysis directed toward the prevention, detection and deterrence of fraud, waste and abuse
Create, modify, maintain, and enhance existing programming or business processes associated with specific responsibilities
Interpret, communicate, and present results to all levels of management in consistent and easy to understand formats to facilitate fact-based decision-making
Complete projects within preset timelines and report status to supervisor and project manager
Prepare written documentation on projects to provide a peer review trial and ensure continuity and integrity
Build and maintain close working relationships with internal stakeholders and key external client contacts (e.g. Providers, Internal Clinicians, Vendors, Customers, BCBS Association, Blue Plans, Auditors and all local, state and governments agencies
Develop processes, write queries and/or create databases using analytic tools to produce accurate and timely completion of analytic solutions
Model financial impact analysis for trends and schemes identified
Collaborate with peers to establish, evaluate, and continually improve measurement methodologies, while adhering to nationally accepted analytic and reporting standards
Manage, manipulate and mine data to respond to various requests for reporting purposes as well as identify fraud, waste and abuse trends and perform root cause analysis and further refine reports to reflect irregularities/aberrations.
Performs moderately complex data analysis techniques in in the determination of the existence of fraud, waste and abuse schemes. Utilizes the data analysis capabilities of the fraud software to assist in determining the merit and potential exposure of specific allegations. Also utilizes fraud software reports as a tool when proactively detecting schemes and potential company exposure.
Perform complex analysis and interpret complex calculations to recommend actions and solutions
Develop financial models needed to accomplish analytic goals
Serve as a subject matter expert for internal stakeholders
Make sound assumptions and fact-based recommendations and discuss with supervisor, manager, or project manager
Effectively communicate results and recommendations to internal and external customers
Provide self and peer review of job responsibilities
Share knowledge of skills, projects, and business needs with peers and less-experience analysts. Train new analysts
Report to a supervisor or manager who provides general supervisory instructions, manages projects and review results. Develop own work-plan, and discusses timelines, prioritization, and objectives with supervisor or manager.
Drive and implement complex and critical analytic initiatives with minimal oversight
Create and research analysis and recommendations, which help, achieve corporate initiatives and goals
Review results –post-implementation to ensure projections are realized and recommend modifications as applicable
Produce complex analytic solutions and consolidate complex analytics into easy to understand presentations focused on business implications
Plan and lead complex analytic project from inception to completion. Includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementation the project and resolving/monitoring post-implementation issues
Communicate (both verbally and in writing) and interpret results, recommendation and abstract concepts to internal and external customer. Anticipate and address possible customer questions and concerns
Incorporate strategic planning in all areas of responsibility
Train and mentor other analysts
Required Work Experience
3 years of experience in data analysis using analytic tools and processes, working for a healthcare organization / health insurer / investigative industry and knowledgeable in medical coding and medical terminology (level 2)
5 years of experience in data analysis using analytic tools and processes working for a healthcare organization / health insurer / investigative industry and knowledgeable in medical coding and medical terminology (level 3)
Bachelor's Degree in mathematics, statistics, business, or related field of study (Applies to All Levels)
Preferred Work Experience
4 years of experience in data analysis using analytic tools and processes working for a healthcare organization / health insurer / investigative industry and knowledgeable in medical coding and medical terminology, including development of business analytics and financial impact analysis (level 2)
6+ years of experience in data analysis using analytic tools and processes working for a healthcare organization / health insurer / investigative industry and knowledgeable in medical coding and medical terminology, including development of business analytics and financial impact analysis (level 3)
Master’s Degree in mathematics, statistics, business, or related field of study. (Applies to All Levels)
CFE, AHFI, CPA, CPC
Required Job Skills (Applies to All Levels)
Intermediate PC proficiency
Intermediate proficiency in database, presentation, spreadsheet and word processing software
General proficiency in mathematical concepts
Intermediate understanding of data management principles
Advanced analytical and problem solving skills with demonstrated experience conducting research, locating and extracting appropriate enterprise-wide data from databases, developing business intelligence reports, analyzing and interpreting data, and providing summary report recommendations
Intermediate proficiency in computer programming, including SAS and other business intelligence programs
Intermediate skill with SAS/SQL programming (Applies to Levels 2 – 3)
Advanced understanding of data management principles (Level 3)
Proficiency in SAS Enterprise Business Intelligence software (Level 3)
Intermediate skill with data visualization tools, such as Tableau (Level 3)
Required Professional Competencies (Applies to All Levels)
General knowledge of the healthcare industry
Broad understanding of medical terminology, coding, provider contracts, medical coverage guidelines and pricing policies
Analytical knowledge necessary to generate analytic solutions
Ability to solve problems independently and draw accurate conclusions from data using basic analytic techniques
Ability to deal with ambiguity and make recommendations with less than complete or conflicting information
Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints
Ability to maintain confidentiality and privacy
Ability to communicate effectively, both orally and in writing, to all levels in all departments
Ability to distill and communicate financial levers and impacts to non-technical audiences
Ability to build and maintain productive working relationships with others
Proactive about requesting enough information to fully understand and meet the business need
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Internal Number: 4832
About Blue Cross Blue Shield of Arizona
Since 1939, BCBSAZ has become one of the most trusted and recognized companies in the Valley. Our stability, long history and brand recognition all contribute in helping us to attract and retain talented employees.
BCBSAZ is an equal opportunity employer and is committed to maintaining a drug-free work environment. The selection of qualified candidates for employment opportunities is based on organizational requirements.
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