Senior Ideation Analyst

HMS Healthcare
Full time
United States
Hiring from: Anywhere

Title: Senior Ideation Analyst

Location: United States

Classifications: Remote

HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcarenow and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.

We are seeking a talented individual for a Sr. Ideation Analyst who performs research analytics to support our recovery audit line of business. Primary focuses of the position would include: identify new audit concepts, write specifications used to identify claims paid in error, audit paid claims data through multiple tools and methods, and perform quality assurance checks on existing concepts. In your role, you will assist in the development and implementation of new data mining opportunities and audit/review methodologies for identifying healthcare overpayments made to providers by insurance companies through data review and analytics.

Essential Responsibilities:

  • Research client, State and Federal billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stake holders) to develop and configure improper payment algorithms. Results will need to be organized, documented, and trained to other team members

  • Reviews provider contracts to identify algorithms for the identification of contractual based overpayments

  • Performs scoping analysis and development of new overpayment algorithms

  • Applies knowledge of provider billing and patient accounting practices to research client policy and data to reveal new overpayment recovery opportunities. Works with other team members, clinical staff, and key stakeholders to identify new overpayment issues for each client

  • Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements

  • Develops data extract specifications to select claims not paid in accordance with regulations for programming with trained engineers

  • Monitors internal systems used for tracking audits and findings to ensure high degree of accuracy and maximum productivity

  • Participate in query development process and reports query development progress and outcomes to leadership, internal and external clients, where necessary

  • Ensures individual and departmental goals are consistently met or exceeded, in collaboration with other team members and management

  • Reviews IT programming results for quality assurance and proof of concept validation

  • Documents results and supports preparation of internal and external documentation and presentations related to research and new overpayment issues

  • Works with internal operations and clinical teams to develop, implement, review and audit protocols and internal review guidelines

  • Uses advanced analytics to identify overpayment opportunities

  • Develops and validates workflows and communication tools to best enhance audit production, client satisfaction, and quality assurance

  • Works with data scientists and engineers to develop and implement technological improvements that will support the audit process

  • Contributes new ideas for improving existing audit processes and audit queries.

  • Works cohesively with the entire audit team and internal clients

  • Acts as a team lead in assisting and guiding lower level analysts

  • Develops, maintains, and ensures adherence to multiple project schedules

Non-Essential Responsibilities:

  • Performs other functions as assigned


Knowledge, Skills and Abilities:

  • Willing and eagerness to learn and adapt with the growth of the business and drive efficiencies through continuous process improvement without implementing undue complexity

  • Proactive in promoting management initiatives, supporting the implementation of change across the analyst team, and collaborating with operational and IT/Engineering teams

  • Demonstrate excellent analytical and modeling skills and the ability to apply them to business situations for value creation

  • Uses advanced analytics to identify overpayment opportunities

  • Ability to learn new tools with minimum guidance and work independently

  • Demonstrated ability to meet and exceed project deadlines while producing high quality products

  • Knowledge of health care information (e.g., health claims data specifically Medicare and Medicaid), ICD-9/10-CM codes, and physician specialty codes)

  • Works with data scientists and engineers to develop and implement technological improvements that will support the audit process

  • Knowledge of claims processing systems and contract configuration requirements (e.g., FACETs, QXNT, NASCO, etc.)

  • Contributes new ideas for improving existing audit processes and audit queries

  • Review and enhance parse logic and text libraries to create efficiency in HMS Products

  • Must have demonstrated knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-10-CM codes, HCPCS codes, CPT codes, DRGs, etc.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment or work from home

  • Ability to communicate and exchange information

  • Ability to comprehend and interpret documents and data

  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)

  • Requires manual dexterity to use computer, telephone and peripherals

  • May be required to work extended hours for special business needs

  • May be required to travel between offices or to Client locations based on business needs

Minimum Education:

  • Bachelor’s degree required

  • Master’s degree preferred

Certifications: (Desired)

  • Tableau Desktop Specialist, Tableau Desktop Certified Professional, Tableau Desktop Certified Associate

  • Python: PCEP, PCAP, PCPP-32-1, PCPP-32-2, CEPP

  • Coding Certifications: CPC, COC, CIC, CRC, CPB, CPMA, etc

Minimum Related Work Experience:

  • 5+ years of related data analysis experience including at least 3 years recent experience healthcare claims data

  • 5+ years’ experience with Microsoft SQL Studio, Teradata, PostgreSQL, Python, R, Alteryx, DataMeer, Tableau, DataRobot, or similar analytical tools

  • 3+ years reviewing contract language, system configuration, and facility payments

  • Knowledge of CPT, ICD-10-CM, and HCPCS Level II coding guidelines

  • Experience developing, deploying and documenting ETL Processes

  • Experience designing and implementing analytical products or process improvements

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

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