Analytics Consultant
Location: Chattanooga, Tennessee
Description: BlueCross BlueShield of Tennessee is at the momment seeking for Analytics Consultant right now, this vacancy will be depute in Tennessee. More details about this vacancy opportunity please read the description below. NOTE: This position will be filled as either a Research & Trending Consultant (Req # 1302037) or as a Analytics Consultant (Req #1302038) depending on qualifications of ap! plicant pool.
This position is responsible for detecting and analyzing potential for fraud, waste or abuse of healthcare and healthcare dollars as well as working alongside Enterprise Integrity Services (EIS) Investigators and Auditors with resulting cases and audits. Decisions reached and actions taken by the incumbent in this position can have a significant financial and liability impact on BCBST, our accounts and customers.
Job Duties & Responsibilities
- Thoroughly analyze and research all aspects of a referred request or case to determine whether or not aberrant billing, fraudulent activity, inappropriate coding, low quality of care or activities causing inappropriate reimbursement or indicating other inappropriate behavior may be apparent.
- Take action on requests using, but not limited to, the following techniques:
o identify medical, business or any other records that might be applicable to any review;
o coordinate analytic activities with internal and external consultants;
o gather details from providers, members, vendors and others associated with the request, audit or case.
- Apply the following analysis/data mining/reporting tools and others as most appropriate for the situation under analysis: COGNOS 8, FAMS, SAS, Microsoft Access, and Microsoft Excel.
- Prepare a detailed analysis document with narrative and graphics (as appropriate) to comprehensively and concisely describe the findings of research and analysis.
- Make recommendations for future actions including but not limited to: forward researched issues to audit/investigations/other Blue Plan, submit for claim(s) adjustment(s), submit issues to Clinical Risk! Management, etc.
- Troubleshoot configuration issues related to claims payments and benefit issues.
- Work closely with Provider Audit and Investigative staffs to provide analytical support as the audit or case proceeds, which may last for a substantial length of time.
- Select claims for audit based upon analysis results and potential likelihood for recovering BCBST monies.
- Coordinate with BCBST Legal Division and the Enterprise Investigative team to provide information to external attorneys and law enforcement agencies.
- Testify in criminal and civil proceedings as necessary regarding BCBST data, access methods, analysis methods and reporting tools.
- Actively participate on various internal committees and external fraud tasks forces and keep Analytics management informed of those discussions while proposing ways to incorporate new ideas into workflow.
- Work as a liaison between BCA plans regarding payment and reviews ! related to Fraud, Waste, and Abuse.
- Assist the Business Resear! ch Project Coordinator and the Research and Trending Consultants as necessary.
Job Qualifications
Education
- Bachelor’s degree from an accredited college in health-related data/information analysis field or equivalent related work experience, defined as 7 years successful experience working with health care claims in capacities such as adjudication, customer service, and data analysis/research.
- Proven successful experience in claims data analysis or research concerning healthcare fraud/abuse is preferred.
- Experience utilizing specialized fraud detection software applications (such as FAMS, STARS, TRAPS, etc.) is preferred.
- Minimum of 7 years experience with the BCBST claims/financial/member data and systems (ex: Facets, FEP, ITS, Blue2) is strongly preferred.
- Experience and a high degree of expertise in Microsoft Office products such as Access, E! xcel, Outlook, and Word.
- Possess a good working knowledge of medical terminology and experience working with medical information.
- Possession or progress toward one or more of the following certifications/designations: HIA, MHP, HCAFA, PAHM, ALHC, CCA, CPC, CCS, or CCS-P. If not possessed at the time of hire, will meet expectation to obtain one of the designations within 2 years.
- Coding certification through the AAPC or AHIMA is a plus.
- Ability to design, code, and execute data queries/models in Microsoft Access, COGNOS 8, IBM FAMS, and/or SAS for use in analysis of potential fraud/abuse activities. If this skill is not well developed upon hire, the aptitude must be possessed so the skill can be well-demonstrated within the first 3 months of hire.
- Ability to act as a mentor for junior staff and new employees as well as play a key role in training activities for the EIS and Provider Audit d! epartments.
- Possess the ability to interpret and apply contrac! t provisions and benefit language to specific situations and facts and reach accurate conclusions that are based on solid analytical and logical decision making abilities.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to BlueCross BlueShield of Tennessee.
Interested on this vacancy, just click on the Apply button, you will be redirected to the official website
This vacancy will be started on: Wed, 09 Oct 2013 21:45:01 GMT
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