Resp & Qualifications
PURPOSE: Assist the manager in the production of utilization and financial performance reports for hospitals and other institutions and develop complex modeling tools, perform profile analysis, and prepare spreadsheets,
PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager, Special Investigations Unit, responsibilities include, but are not limited to:
Duties and Responsibilities
1. Responsible for the data quality and data integrity for all reports generated by the data team.
2. Responsible for supporting the prevention, detection, investigation, reporting and when appropriate, recovery of money related to health care fraud, waste, and abuse across the organization, which includes generating accurate and timely analysis and reports to support the SIU initiatives to identify fraud, waste and abuse.
3. Responsible for importing, cleaning, transforming, validating or modeling data with the purpose making conclusions from the data for decision-making purposes.
4. Present findings individually or with a group of his/her peers that cooperatively works to give SIU management and associates a synopsis of their findings.
5. 5% Work closely with the SIU Forensic Analyst in preparing SIU outlier reports and analysis for use by the department when determining whether to pursue an investigation and/or to provide additional information during an investigation.
• Bachelor’s degree in IS or related qualitative field (finance, computer science, mathematics, etc.), and 2-5 years of business experience in a health care environment OR total equivalent work experience.
• Must have working knowledge of the managed health care business, including data analysis and medical coding.
• Possess strong math and analytical skills.
• Excellent PC skills including a working knowledge of Microsoft ACCESS and EXCEL and relational databases/SQL Server.
• Strong background in extracting and compiling data, creating reports, and displaying information, along with experience combining clinical and financial data.
• Ability to handle multiple priorities/projects in a fast-paced professional environment.
• Demonstrate performance in meeting time-sensitive deadlines with minimal supervision.
• Demonstrate adaptability and flexibility to changes, responsive to new ideas, systems, and ad hoc requests.
• Ability to abide by CareFirst’s policies.
• Participate in and update personal goals and objectives.
• Ability to analyze difficult, sensitive, and/or confidential situations.
• Excellent verbal and written communication skills.
• Maintain regular attendance based on agreed-upon schedule.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
• Computer literacy and use of applicable systems and software.
Preferred: Expertise in related healthcare fields and proficiency using profiling tools such as DRGs, CPT and HCPCS codes is strongly preferred. Financial reporting and analysis in a hospital or other medical institutional environment is also strongly preferred. Knowledge of institutional contracting principles and reimbursement philosophy is desired. Knowledge of CareFirst organization, operations and adjudication systems is preferred but not necessary. Knowledge of DC and MD mainframe applications including BCIQ, PVXI and PV40 is desirable but not required. Experience with TSO, FileAid, SQL, DB2, and EZTrieve programming languages are preferred.
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 2/15/2021
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship