Senior Cost Containment Analyst

What You Will Do

• Runs cost avoidance reports to analyze and validate managed care claims and comp grids against provider contracts, member eligibility, benefit grids, and authorization data to ensure VNS Health 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.
• Analyzes recovery and negative balance dashboard validating accuracy, timeliness, and performance of recoveries
• 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.
• Assists encounter team in ensuring alignment of claims to encounters.
• Maintains check request and recovery letter trackers assuring reviews are done timely and recovery payments from providers are logged appropriately.
• Participates in special projects and performs other duties as assigned.

Education:

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

Work Experience:

• Minimum of three 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
• Proficiency in data analysis software such as SAS, R, or Stata. preferred Proficiency with SQL preferred Excellent communication and analytical skills required