VNS Health Looking for Cost Containment Analyst at The Bronx, NY  Full Time

Conducts 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

Responsibilities
* 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 preferably in Technology, Information Science, Mathematics or statistics 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

VNSNY is an equal opportunity employer M/F/D/V https://tbcdn.talentbrew.com/company/1238/v1_0/img/eeopost.original.pdf