Cost Containment Analyst

OverviewConducts analysis of claims and payment data across health plans in support of ensuring payment integrity and cost containment. Identifies anomalous utilization patterns, investigates cost containment, and tests alignment with vendor's contracted rates. Reconciles and validates underlying analytic data claims, and utilization management systems. Tests the integrity of utilization and payment data across plans and functions. Engages in activities to support corrective actions to functions, Operations and Compliance as directed. Works under general supervision

Compensation Range:$70,200.00 - $87,700.00 Annual

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability    
• Employer-matched retirement saving funds   
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care   
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth and career advancement    
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities   

What You Will Do

• Assists the Manager in analyzing and validating managed care claims and comp grids against provider contracts, member eligibility, benefit grids, and authorization data to ensure Health Plans pays our Providers appropriately and contains cost.
• Investigates utilization and claims coding patterns to identify potential fraud, waste or abuse and coordinates with Compliance and Special Investigation Unit for recoveries as necessary.
• Analyzes affordability of medical cost against premium revenue for membership panels of providers, in specific settings, or across other attribution categories as appropriate.
• Communicates with internal departments (i.e. Claims, Providers, Finance etc) to validate existence of integrity leakage points, and coordinates to develop and implement corrective solutions and recovery.
• Validates accuracy, timeliness, and performance of claims processing vendor as directed.
• Attends meetings with analytics teams, product teams, operations, and allied departments to communicate status of investigative projects and identify new areas of opportunity or priorities. Keeps management informed as necessary.
• Utilizes analytic data warehouse and native claims systems and other supporting data for investigation.
• Conducts targeted analysis to support regulatory investigations; provides claims extracts and supporting data as required.
• Conducts analysis of delegated vendor claims data to test affordability, support contract negotiations, and identify potential errors or Fraud, Waste, and Abuse for further investigation by Special Investigation Unit Compliance, or other departments.
• Assists encounter team in ensuring alignment of claims to encounters.
• Participates in special projects and performs other duties as assigned.

Qualifications

Education:

• Bachelor's Degree Bachelor's degree in Technology, Information Science, Mathematics statistics, or the equivalent work experience required

Work Experience:

• Minimum of two years managed care claims analysis experience required
• Experience in financial or operational analytics preferred
• Knowledge of Medicare and NYS Medicaid claims processing rules and coding experience with DRG, ICD10 and CPT4 required
• Proficiency in standard business applications such as Microsoft Office required
• Proficiency in claims processing platforms such as FACETS required preferred
• Proficiency in data analysis software such as SAS, R, or Stata preferred
• Proficiency with SQL preferred required
• Excellent communication and analytical skills required