Job Description

The role will be responsible for creating, refining and performing various analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the position will be required to conduct preliminary research of identified providers or members to include public record, contract, and social media review, among others. The analyst will be accountable for documenting analytic and research activities within concise reports or memoranda.
Essential Functions
-Develop and run reports, analyze data to identify suspicious billing patterns, assess the merits of allegations, and present those findings to leadership.
-Analyze claims data to find suspicious billing patterns and outliers, using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerabilities.
-Conduct preliminary investigations to assess the merits of allegations through fact-gathering and analyses of data sets.
-Organize data and document preliminary investigative steps with a high level of detail and accuracy to clearly and concisely support investigative inferences, conclusions, and recommendations.
-Report discoveries of fraud or program abuse to external parties, as required by law, rule, or contract.
-Receive investigative requests from field staff, internal claims associates, and underwriting.

Education

• Bachelor's Degree

Experience

• At least 2-3 years of experience investigating claims or compliance required
• At least 2-3 years of experience as an analyst in healthcare, data reporting or data analysis required
• Healthcare fraud experience highly preferred
• Data analysis with SQL proficiency highly preferred

Knowledge, Skills, and Abilities

• Strong verbal/written communication skills.
• Excellent analytical, critical thinking, and organizational skills.
• Comprehensive knowledge of CPT, HCPCS, ICD10-CM diagnosis, and procedure codes.
• Strong aptitude for technology-based solutions.
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

Working Conditions

• This is a hybrid role with at least one team meeting onsite per month
• This is a full-time position with five 8-hour days (typical schedule is 8:30 am EDT - 5:00 pm EDT)

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Job Tags

Full time, Contract work,

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