Business Analytics Senior Manager

Role Description

The Sr. Mgr. Business Analytics is responsible for developing, maintaining, and automating reports and dashboards that track the performance of medical and payment policies. By delivering data-driven insights to leadership and other stakeholders, this role helps optimize business processes, ensure policy compliance, and identify opportunities for efficiency improvements and cost savings.

Data Analysis & Reporting:

• Extract, validate, and interpret large datasets from healthcare claims, authorizations, and payment systems.
• Conduct exploratory data analysis to identify patterns, trends, and deviations in payment or utilization.
• Evaluate medical and payment policy operations, identifying trends, patterns, and variances related to:
  • Medical cost drivers and utilization patterns.
  • Effectiveness of medical and pre-payment policies, and precertification for delivery of insights on performance to leadership.
  • Operational efficiency metrics, such as turnaround times and productivity.
  • Policy compliance and adherence to regulatory requirements.

Policy Quality & Compliance:

• Review payment policies and procedures for accuracy, identifying gaps and potential inaccuracies.
• Ensure adherence to medical policies and regulatory requirements, such as federal and state legislation and HIPAA.
• Participate in the design and deployment of algorithms or automated edits to ensure correct payment and prevent overpayments.

Business Process & System Improvement:

• Collaborate with stakeholders to gather business requirements for new systems and process improvements.
• Translate complex analytical findings and business needs into clear documentation and actionable strategies.
• Provide training and ongoing support to end-users on new systems, processes, and analytical tools.

Report and Dashboard Development:

• Design, build, and maintain standard and ad-hoc operational reports and interactive dashboards using business intelligence tools (e.g., Power BI, Tableau).

Requirements Gathering:

• Collaborate with stakeholders from clinical operations, finance, and other departments to gather business requirements for new reports and analytical projects.

Data Integration and Quality:

• Extract, integrate, and validate data from multiple sources, including claims, membership, and provider data.
• Conduct root-cause analysis of data irregularities and ensure data accuracy.

Communication of Insights:

• Interpret complex data findings and effectively communicate insights and recommendations to both technical and non-technical audiences through clear visualizations and presentations.

Automation:

• Automate recurring reporting processes and workflows to improve statistical efficiency and free up resources for more complex analysis.

Qualifications

• 5-7+ years of experience in a data or business analyst role, preferably within the healthcare or health insurance industry with payment integrity.
• 2-3 years analyzing claim editing rules for payment accuracy and trends.
• Demonstrated proficiency in SQL for querying and manipulating large datasets.
• Experience in developing reports and dashboards using data visualization tools like Microsoft Power BI, Tableau, and QuickBase Tools.
• Experience with claims data, eligibility data, and medical and payment policy analytics.
• Knowledge of healthcare industry coding systems, including ICD-10 and CPT.
• Familiarity with data governance concepts and data management best practices.

Preferred

• Medical coding certification, i.e., Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or other certifications preferred.

Education

• Bachelor's degree in a field such as Finance or Mathematics, or similar field.

Pay Range

The typical pay range for this role is: $67,900.00 - $182,549.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.

Benefits

• Comprehensive and competitive mix of pay and benefits.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.