Cost Containment Analyst
Company: VNS Health
Location: New York
Posted on: March 20, 2023
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
--- 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.
Bachelor's Degree preferably in Technology, Information Science, Mathematics or statistics required
Minimum of two years managed care claims analysis experience requiredExperience in financial or operational analytics preferredKnowledge of Medicare and NYS Medicaid claims processing rules and coding experience with DRG, ICD10 and CPT4 requiredProficiency in standard business applications such as Microsoft Office requiredProficiency in claims processing platforms such as FACETS required preferredProficiency in data analysis software such as SAS, R, or Stata preferredProficiency with SQL preferred requiredExcellent communication and analytical skills required
VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 125 years, our commitment to health and well-being is what drives us-we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNSHealth team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 "neighbors" who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNSHealth offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.Explore this LocationGet an idea of what your daily routine around the office would be likeRegister to be notified as soon as new jobs become available. Email Address Select a job category from the list of options. Select a location from the list of options. Finally, click "Add" to create your job alert. Job Category Location
Keywords: VNS Health, New York , Cost Containment Analyst, Professions , New York, New York
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