Senior Analytic Consultant develops algorithms analyzing Medical, Dental. Managed Care, and Pharmacy claims data to detect fraud, waste and abuse to support the Missouri Medicaid Audit and Compliance Division’s (MMAC’s) program integrity operations. Prepares formal write-ups detailing the analysis performed while highlighting suspicious providers, trends, outliers and potential overpayments. Works with Medicaid Program Integrity (PI) Subject-Matter Experts (SMEs) and the Project Director to refine analyses and prepare presentations to MMAC, and collaborates with managed care organizations’ special investigation units (SIUs).
Analyze health care claims data for the State Medicaid Surveillance Utilization Review Program Integrity department to identify potential fraud and abuse by providers and/or recipients. Prepare formal write-ups detailing algorithm parameters, programming and results. Present effective, polished presentations of these results to clients.
Research Missouri policies, provider manuals and provider communications; Federal and Missouri regulations and statutes; and coding guidelines related to analytic projects. Translate this policy into data analysis.
Perform drill down reporting on suspicious providers and/or recipients and create reports to show the dollars paid and the potential recovery. Provide recommendations for next steps in the investigation of algorithm results, opportunities for Missouri Medicaid policy clarification, provider education and/or claim edit enhancement as methods of cost avoidance.
Work in a team setting and independently performing detailed claims analysis using Truven’s tools which are proprietary software tools. Participate in training to learn these tools.
Update internal team databases and the case tracking tool to reflect project status.
Peer review algorithm logic and write-ups for other Senior Analytic Consultants.
Create draft provider audit letters and mail merges for completed algorithms.
Provide on-site and/or telephone support (e.g., client inquiries, ad hoc reporting assistance, miscellaneous research, advice on analytic methods) and training as requested by client end users and management.
Through the use of analytic findings, define problems and recommend appropriate solutions to clients, other team members and management taking into account the project budget, the sophistication of the user and the intended use of project results.
Demonstrates increasing responsibility for completion and ownership of projects and/or tasks with a significant impact on a department or function.
Required Technical and Professional Expertise
2+ years as an Analytic Consultant, a Data Scientist or related quantitative analysis field
2+ years Medicaid experience required
Experience utilizing data analytics tools to develop algorithms or analytics
Experience with data validation and data integrity testing
Ability to analyze large data sets to draw relevant conclusions and make educated decisions
Previous knowledge of healthcare insurance claims from clinical or administrative experience
Experience in applying health analysis methods and measures utilizing basic statistical methods
Experience transforming raw data into visual interpretations
Excellent oral and written communication skills and outstanding presentation skills.
Excellent time management techniques and the ability to develop creative solutions to enhance processes
Knowledge of SAS, SQL, Access, or similar data analysis software tools as well as MS Excel
Preferred Tech and Prof Experience
Registered Health Information Administrator (RHIA), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI) certifications preferred
Experience with managed care program integrity issues a plus
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