Senior Cost Containment Analyst

VNS Health • New York, NY

6d

About The Position

Compiles, analyzes, and interprets overpayments through quarterly trend reporting for cost avoidance and recovery initiatives. Co-ordinate with business to align with payment recoveries disseminating findings for affordability initiatives. 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

Requirements

• Bachelor's Degree Bachelor’s degree required preferably in Technology, Information Science, Mathematics or Statistics or the equivalent work experience required
• Minimum of three years managed care claims analysis experience required
• 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
• Excellent communication and analytical skills required

Nice To Haves

• Experience in financial or operational analytics preferred
• Proficiency in data analysis software such as SAS, R, or Stata preferred
• Proficiency with SQL. preferred

Responsibilities

• 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.

Benefits

• 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 This Job Offers

• Job Type: Full-time
• Career Level: Mid Level