Senior Business Analyst, Claims and Vendor Data

REMOTE

Summary of Position

• Develop/gather business requirements for queries needed to analyze vendor payment data.
  
  
• Utilize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year.
  
  
• Analyze and interpret claims, payment, and vendor data to identify, prevent, and recover overpayments, as well as to drive process improvements and cost containment.
  
  
• Leverage data analytics, competitor benchmarking, and outcomes to continually identify savings opportunities; to detect trends, discrepancies and inefficiencies, and to support corrective actions.
  
  
• Collaborate with internal teams and vendors to optimize financial recovery and ensure compliance with regulatory and contractual requirements.
  
  
• Develop mitigation strategies to avoid future overpayments/underpayments and implement plans to achieve business goals.

Principal Accountabilities

• Work directly with management on highly visible projects to understand business needs and current challenges, developing innovative solutions to meet those needs.
  
  
• Assist in the development of a comprehensive claims strategic roadmap to recover, eliminate, and prevent unnecessary medical overpayments by reviewing upstream and downstream processes.
  
  
• Assist in the design and delivery of presentations on project status and outcomes to management.
  
  
• Proactively identify and investigate payment issues, developing mitigation strategies, workflow and process impacts, root cause analysis, and member/provider impact.
  
  
• Collaborate with internal teams (Claims, COB, Provider Network Management, Finance, etc.) to integrate overpayment prevention strategies.
  
  
• Maintain and apply knowledge of current trends, practices, and developments in healthcare.
  
  
• Analyze financial recovery vendor operations to ensure compliance with contracts, regulations, internal policies, and SLAs.
  
  
• Develop and execute vendor management strategies to maximize recoveries on negative balances, offsets, and overpayments.
  
  
• Analyze vendor performance data to identify trends, gaps, and areas for corrective action or process improvement.
  
  
• Establish and track KPIs and SLAs for all vendors to drive accountability.
  
  
• Assist with the resolution of escalated issues for alignment on overpayment prevention strategies.
  
  
• Report on vendor performance, recovery metrics, and process improvement initiatives to leadership and stakeholders.
  
  
• Identify overpayment/underpayment opportunities via data mining, investigations, and quality reviews (benefit configuration, COB, claims logic, etc.).
  
  
• Collect, compile, and analyze data to measure and report on current and process enhancements. Structure large data sets to find usable information and define, design, and create reporting solutions with actionable insights.
  
  
• Create reports for internal teams, external clients, and stakeholders with data visualizations (graphs, dashboards, infographics).
  
  
• Produce standard periodic reports and ad hoc analyses as requested.
  
  
• Utilize Excel, Power BI, Tableau, and other tools to analyze performance drivers and create dashboards for selfmanaged reporting.
  
  
• May write and execute SQL queries to support data validation, reporting, and issue resolution.
  
  
• Conduct regular gap analyses of internal and vendor processes to identify and mitigate risks for overpayments.
  
  
• Perform gap analyses on claims data to identify discrepancies, compliance risks, and opportunities for process improvement.
  
  
• Identify opportunities for process enhancements to streamline workflows, reduce errors, and prevent overpayments.
  
  
• Drive continuous improvement initiatives by recommending and implementing best practices in payment integrity and overpayment prevention.
  
  
• Collaborate on the design and implementation of internal controls and process improvements.
  
  
• Monitor process designs to measure operational effectiveness and improve performance of key metrics.
  
  
• Participate in interdepartmental work groups in support of process improvement projects.

Qualifications

• 4 - 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required
  
  
• Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree
  
  
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation required
  
  
• Experience in claims business process analysis, preferably in healthcare (i.e. documenting business process, gathering requirements) or claims payment/analysis required
  
  
• Experience in a hospital or managed care environment with a focus on claims data analysis, provider contracting, or decision support, especially in cost and utilization analysis required
  
  
• Understanding of NYS, CMS and Medicaid reimbursement guidelines; a working knowledge of industry coding (revenue codes, ICD 9 classifications, CPT codes, etc.). Familiarity with claim coding practices and industry issues in payment methodologies; strong problem solving, root cause analysis, critical thinking skills, and meticulous attention to detail required
  
  
• Technical knowledge of health insurance claims/Financial Recovery/Vendor Oversight required
  
  
• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes; and to identify and interpret trends, patterns, and anomalies within complex datasets of trend information required
  
  
• Experience working with internal or external stakeholders to understand business needs and translate them into technical solutions; to manage expectations; and provide HIPAA-compliant guidance to business partners, vendors, and end-users, per industry standards for EDI protocols required
  
  
• Strong understanding of data structures, relational databases, and query logic required
  
  
• Excellent communication skills (verbal, written, presentation, collaboration, persuasion); with all types/levels of audiences; ability to influence management decisions required
  
  
• Experience in Continuous Improvement Management for Operations and process mapping/documentation required
  
  
• Energy, drive and passion for End-to-End excellence and customer experience improvement required
  
  
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) and other data systems required
  
  
• Proficiency in SQL for data querying/analysis; data visualization tools such as Power BI/Tableau Reporting or similar preferred
  
  
• Ability to work collaboratively with cross-functional teams required
  
  
• Skilled in presenting data findings in a clear and accessible format to both technical and non-technical audiences. Familiarity with data visualization best-practices and interactive dashboard development required

• Requisition ID: 1000003156
• Hiring Range: $68,040-$118,800

Required

Preferred

Job Industries

• Other