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Description
Job Description
Job Title:
Mgr Coding Validation Initiative Analysis
Job ID:
11048
Location: Virginia Beach, VA
Full/Part Time:
Full-Time
Regular/Temporary:
Regular
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Responsibilities
JOB SUMMARY: The Manager for Coding Validation Initiative (CVI) Analysis is responsible for the extraction, management, and analysis of data from internal/external operational processes, data repositories, business systems, and records to identify abuse and waste risks in support of CVI business objectives. Associate develops, implements, manages, and utilizes technology solutions. Performs complex data mining, ad hoc analysis, and reporting functions to quantify exposures due to provider abusive and wasteful billing patterns. Develops prioritization strategies and recommendations for reviews. Collaborates directly with associates, other departments, external agencies, and vendors in support of Department and Corporate initiatives (ex. projects and reviews).
PRIMARY RESPONSIBILITIES:
1. Performs complex data mining and ad hoc data analysis to identify patterns of suspicious activity, outliers, anomalies and other issues that represent waste or abuse risk.
2. Develops advanced data analysis tools, methodologies, techniques, and technology solutions to support Department business objectives.
3. Quantifies, prioritizes, and develops strategies for reviews, based upon data mining/analysis.
4. Designs and implements Access databases, queries, and reports. Designs and implements SQL Server tables and stored procedures. Utilizes multiple Corporate data repositories, including SQL Server and Oracle databases.
5. Develops management reporting tools to provide business intelligence required to make effective decisions.
6. Utilizes a variety of applications (Access, Query Analyzer, SQL Server, STARSentinel, AMISYS, and Facets) to achieve comprehensive analysis and support.
7. Identifies technology solutions for process improvements and automation.
8. Understands healthcare waste and abuse detection and prevention methodologies, practices, and theories. Understands departmental, corporate, and external business objectives and processes. Applies knowledge in technology solution development.
9. Collaborates directly with associates, other departments, external agencies, and vendors to coordinate resources, analyze data, identify trends, and communicate findings.
10. Effectively communicates with Department, senior management and external agencies, in a timely, accurate, and professional manner.
11. Provides technical support for analysis, database, query, application, and reporting issues.
12. Trains and coaches associates in data analysis.
13. Continues to improve technical skills and leadership ability.
14. Continues to stay current with changes in corporate data resources and company initiatives/objectives.
15. Maintains technical expertise and stays abreast of developments in the data analysis, waste and abuse, managed care, and information technology (IT) fields.
16. Performs other duties as assigned.
EDUCATION AND EXPERIENCE:
Education
Required:
Bachelors degree in one of the following disciplines: Economics, Statistics, Mathematics, Business Administration, Information Technology, Computer Science, Operations Research, Accounting, Health Information Systems, Nursing, Healthcare Management or other analytical/clinical discipline, and/or equivalent work experience.
Preferred:
Advanced degree in one of the above disciplines.
Years and Type of Experience Required:
Required:
Minimum 6 years experience in analytics role, including data mining, transformation, analysis, and/or reporting, preferably in healthcare, F&A, legal, law enforcement, or IT environments.
Prior experience will include project management, lead role responsibility, and mentoring/coaching of associates.
Preferred:
Experience in healthcare or managed care industry, strongly preferred.
Experience in working within a diverse organization (technical, financial, IT, and operations).
Specific Technical Skills
Required:
Demonstrated experience in MS Access, T-SQL, Query Analyzer, and/or SQL Server.
Demonstrated experience with data mining, transformation, analysis, reporting, and other business intelligence techniques.
Preferred:
Experience with healthcare claims systems (Facets or AMISYS), strongly preferred.
Experience in VB, ACL, PL/SQL, and/or MS Reporting Services, strongly preferred.
Strong level of experience in Access, T-SQL, Query Analyzer, and SQL Server.
Strong level of experience with data mining, transformation, analysis, reporting, and business intelligence techniques.
Certifications or Licensure
Required:
None.
Preferred:
Healthcare or fraud, waste or abuse related certifications or licensure (ex. RN, LPN, CPC, or CFE), or equivalent.
Other
Required:
Demonstrated ability to manage multiple complex projects simultaneously. Strong organization and time management capacity to balance multiple project priorities with limited supervision.
Ability to think creatively and to innovate. Strong conceptual and quantitative problem-solving skills. Demonstrated problem solving and critical thinking skills. Proven effectiveness as a creative problem solver; ability to challenge conventional approaches and think outside the box. Strong investigative skills with ability to search beyond the initial results.
Excellent verbal and written communication skills. Ability to communicate ideas in both technical and user-friendly language. Ability to express complex analytical and technical information to senior management and medical professionals.
Experience working in a team-oriented, collaborative environment. Strong customer service orientation. Good listening and interpersonal skills. Demonstrated leadership and mentoring skills.
Exceptional attention to detail and work product validation
Self-motivated and directed. Works autonomously and with others to identify, isolate, and analyze issues.
Appreciation of cultural diversity and sensitivity towards target population.
Preferred:
Possesses a highly developed quantitative/analytic ability and strategic insights to successfully manage, coordinate, and oversee the design, development, implementation, and tracking of data mining, analytical modeling, and other quantitative risk assessment tools.
Understands and/or learns (quickly) major business processes to design appropriate data analysis tests.
Ability and willingness to learn programming skills to support Department projects.
Skilled communicator with ability to influence others.
SCOPE INFORMATION
Item Measure
# Direct Reports
# Indirect Reports Varies according to projects 5 to 10 typical
Budgetary $ Responsibility Projects impacting millions of dollars in operating costs
PHYSICAL REQUIREMENTS
Travel required (approximately 5%)
Drive a automobile
Travel on a common carrier
Must be able to operate a computer
Must be able to operate a telephone
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
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Details:
Job Id:
731412A1
Posted / Updated:
4/11/2010 4:01:58 AM
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