<p>Summary:</p> <ul> <li>Develop/gather business requirements for queries needed to analyze vendor payment data. </li><li>Utilize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year. </li><li>Analyze and interpret claims, payment, and vendor data to identify, prevent, and recover overpayments, as well as to drive process improvements and cost containment. </li><li>Leverage data analytics, competitor benchmarking, and outcomes to continually identify savings opportunities; to detect trends, discrepancies and inefficiencies, and to support corrective actions. </li><li>Collaborate with internal teams and vendors to optimize financial recovery and ensure compliance with regulatory and contractual requirements. </li><li>Develop mitigation strategies to avoid future overpayments/underpayments and implement plans to achieve business goals. </li></ul> <p>Responsibilities:</p> <ul> <li>Work directly with management on highly visible projects to understand business needs and current challenges, developing innovative solutions to meet those needs. </li><li>Assist in the development of a comprehensive claims strategic roadmap to recover, eliminate, and prevent unnecessary medical overpayments by reviewing upstream and downstream processes. </li><li>Assist in the design and delivery of presentations on project status and outcomes to management. </li><li>Proactively identify and investigate payment issues, developing mitigation strategies, workflow and process impacts, root cause analysis, and member/provider impact. </li><li>Collaborate with internal teams (Claims, COB, Provider Network Management, Finance, etc.) to integrate overpayment prevention strategies. </li><li>Maintain and apply knowledge of current trends, practices, and developments in healthcare. </li><li>Analyze financial recovery vendor operations to ensure compliance with contracts, regulations, internal policies, and SLAs. </li><li>Develop and execute vendor management strategies to maximize recoveries on negative balances, offsets, and overpayments. </li><li>Analyze vendor performance data to identify trends, gaps, and areas for corrective action or process improvement. </li><li>Establish and track KPIs and SLAs for all vendors to drive accountability. </li><li>Assist with the resolution of escalated issues for alignment on overpayment prevention strategies. </li><li>Report on vendor performance, recovery metrics, and process improvement initiatives to leadership and stakeholders. </li><li>Identify overpayment/underpayment opportunities via data mining, investigations, and quality reviews (benefit configuration, COB, claims logic, etc.). </li><li>Collect, compile, and analyze data to measure and report on current and process enhancements. </li><li>Structure large data sets to find usable information and define, design, and create reporting solutions with actionable insights. </li><li>Create reports for internal teams, external clients, and stakeholders with data visualizations (graphs, dashboards, infographics). </li><li>Produce standard periodic reports and ad hoc analyses as requested. </li><li>Utilize Excel, Power BI, Tableau, and other tools to analyze performance drivers and create dashboards for self-managed reporting. </li><li>May write and execute SQL queries to support data validation, reporting, and issue resolution. </li><li>Conduct regular gap analyses of internal and vendor processes to identify and mitigate risks for overpayments. </li><li>Perform gap analyses on claims data to identify discrepancies, compliance risks, and opportunities for process improvement. </li><li>Identify opportunities for process enhancements to streamline workflows, reduce errors, and prevent overpayments. </li><li>Drive continuous improvement initiatives by recommending and implementing best practices in payment integrity and overpayment prevention. </li><li>Collaborate on the design and implementation of internal controls and process improvements. </li><li>Monitor process designs to measure operational effectiveness and improve performance of key metrics. </li><li>Participate in interdepartmental work groups in support of process improvement projects. </li></ul> <p>Requirements</p> <ul> <li> <p>Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree</p> </li><li> <p>4 - 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required</p> </li><li> <p>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</p> </li><li> <p>Experience in claims business process analysis, preferably in healthcare (i.e. documenting business process, gathering requirements) or claims payment/analysis required</p> </li><li> <p>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</p> </li><li> <p>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</p> </li><li> <p>Technical knowledge of health insurance claims/Financial Recovery/Vendor Oversight required</p> </li><li> <p>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</p> </li><li> <p>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</p> </li><li> <p>Strong understanding of data structures, relational databases, and query logic required</p> </li><li> <p>Excellent communication skills (verbal, written, presentation, collaboration, persuasion); with all types/levels of audiences; ability to influence management decisions required</p> </li><li> <p>Experience in Continuous Improvement Management for Operations and process mapping/documentation required</p> </li><li> <p>Energy, drive and passion for End-to-End excellence and customer experience improvement required</p> </li><li> <p>Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) and other data systems required</p> </li><li> <p>Proficiency in SQL for data querying/analysis; data visualization tools such as Power BI/Tableau Reporting or similar preferred</p> </li><li> <p>Ability to work collaboratively with cross-functional teams required</p> </li><li> <p>Familiarity with data visualization best-practices and interactive dashboard development required</p> </li><li> <p>Skilled in presenting data findings in a clear and accessible format to both technical and non-technical audiences required</p> </li></ul> <p>Additional Information</p> <ul> <li>Requisition ID: 1000002852 </li><li>Hiring Range: $68,040-$118,800 </li></ul>