Claims Data Analyst
French Camp, CA•
Under general supervision, responsible for conducting and documenting data claims analysis to identify miscoding trends, potential fraud, and other areas of opportunity.
What you'll do:
- Defines and assists others in defining data, analytic and reporting needs, and interpreting data validity and accuracy.
- Compiles and integrates data from relevant sources.
- Ensures data quality through validation.
- Analyzes, interprets and models data, providing notations of performance deviations and anomalies.
- Designs and presents conclusions using statistical tools, and in consumable formats such as charts and graphs.
- Creates, maintains and publishes periodic and ad hoc reports and other documents; arranges for distribution.
- Assists in identifying and developing appropriate performance measurement tools.
- Assists in preparing for internal and external audits, and in the preparation of recommendations, responses and reports.
What you'll need:
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong business acumen, with the ability to identify which metrics align most closely with business unit goals.
- Strong knowledge of claims data structures and data warehousing.
- Strong knowledge of claims systems, metrics and policies.
- Strong knowledge of medical claims adjudication processes and procedures.
- Strong knowledge of data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
- Strong skills in data visualization and narrative tools and techniques, with ability to position data effectively for consumption and action.
- Strong skills in database manipulation, including the ability to write and run queries (SQL), and link tables.
- Strong skills in data identification, integration, validation, manipulation, interpretation and reporting.
- Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and conduct presentations.
- Basic knowledge of change management theory, with the ability to implement effectively.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Ability to develop, implement and maintain processes, procedures and other guidelines.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
- Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
- Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
- Intermediate skills in Windows, Outlook and PowerPoint.
- Advanced skills in Word and Excel, including the ability to create charts and graphs.
- Strong mathematics skills.
- Ability to handle confidential information with appropriate discretion.
- Ability to speak and be understood in English.
- Knowledge of Medi-Cal, CMS, NCQA HEDIS/CAHPS as they relate to claims processing.
- Knowledge of health plan functions and interactions.
- Knowledge of medical terminology and coding.
What you'll need:
- High school diploma or equivalent
- At least two years performing medical claims or similar analysis; or
- Equivalent combination of education and experience
- Associate’s Degree
- Experience as an analyst in a healthcare claims department or managed care environment
- Knowledge of Medi-Cal Guidelines and billing practices and RBRVS
- Basic knowledge of CPT/ICD 9 and 10, and HCPCS.