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Sr. Consultant Analyst, FEP SIU

Company: 
BCBSA
CIty: 
Washington
State: 
DC
Employment type: 
Full time
Remote Position: 
No
Required degree level: 
Other

Overview

Generates potential fraud waste and abuse leads using post-payment claims data, proactive software tool, and analytical tools. Works with BCBSA FEP SIU, internal and external stakeholders with providing recommendations or system edits to mitigate risk to the program. Utilizes analytical tools to perform clinical, benefit, billing, coding and reviews for services on post payment. Further utilizes medical, contractual, legislative, policy, and other information to validate claims submitted and billed. Conducts research and prepares documentation of findings to provide recommendations to BCBSA FEP SIU business units as it relates to compliance. Assists with other reporting requirements and provides compliance support as needed.

Responsibilities

Responsibilities include but are not limited to:

  • Conducts analysis and uses proactive fraud software to detect fraud, waste and abuse as identified by CS 1039 and the OPM Carrier Letter. Works with BCBSA FEP SIU, internal and external stakeholders providing recommendations or system edits to mitigate risks to the program. Uses analytical tools to perform clinical, benefit, billing, coding and reviews for services on post payment utilizing medical, contractual, legislative, policy, and other information to validate claims submitted and billed. Conducts research and prepares documentation of findings to internal and external stakeholders. Researches and evaluates data from different sources to identify discrepancies and patterns. Interprets clinical and industry literature, applicable regulations, and contract requirements to comply with OPM guidelines and presents status reports to management. Conducts ongoing assessments of trends in coding as it relates to benefit administration.
  • Assists BCBSA FEP SIU with past, current and future audits to ensure compliance. Collaborates with BCBSA FEP SIU business units and BCBSA FEP Program Assurance in providing responses to FWA audit findings. Formulates responses to various audits that affects the FEP SIU program. Provides guidance and input on the annual OPM FWA report.
  • Recommends ways to improve or reduce program risks and minimize costs. Provides consultative support on BCBSA FEP SIU controls, processes and the development and implementation of new procedures to increase operating efficiency and compliance.
  • Participates in various work groups and delivers clear and concise reports to BCBSA FEP SIU Senior management, internal, and external stakeholders.
  • Represents BCBSA FEP SIU at meetings or conferences and provides training and conducts presentations as needed.

Qualifications

Required Basic Qualifications:

  • Bachelor's or Master's Degree in Health Information Systems, Business Administration, Accounting Finance, Auditing, Intelligence, Analytical or other related business discipline, or equivalent experience
  • A minimum of 2 years' healthcare-related work experience
  • Excellent analytical and mathematical skills
  • Good time management abilities
  • Proficient use of proactive software application or analysis of data
  • Minimum of 5 years of compliance or analytical related experience, with progressive responsibilities is required
  • Technical proficiency with various software applications (e.g. Microsoft Windows, WORD, EXCEL, PowerPoint, ACCESS and Outlook)
  • Knowledge/competency examining claims data, researching medical codes and preparing analysis based on post payment claims and financial data
  • Demonstrates the ability to communicate effectively, orally and in writing
  • Demonstrates the ability to research medical procedures, coding, medical policy and benefits to support findings based on data
  • Demonstrates problem solving skills and use of inductive and deductive reasoning to propose solutions for sensitive issues is highly desired
  • Proficient knowledge of Microsoft excel (pivot tables) and access
  • Strong advanced analytical skills with the ability to analyze and interpret data/conduct advanced analysis, and produce reports, formulas and pivot tables and recommendations

Preferred Basic Qualifications:

  • Master's Degree in Health Information Management, Business Administration, Accounting Finance, Auditing, Analytical or other related business discipline, or equivalent experience
  • Certified Coding Certification, or knowledge of claims processing operations and reporting systems
  • Experience preparing a variety of statements, reports, and analyses to support leads or audit findings
  • Experience researching, reviewing and interpreting clinical and industry literature, applicable regulations, and contract requirements
  • Knowledge and understanding of medical benefits, medical policy, and benefit administration, including foundational principles of claims processing
  • Demonstrated experience in leading significant cross-functional work or working groups
  • Ability to work across all levels of the organization, including work with senior management audiences, vendors and the government as a customer
  • Excellent interpersonal and communication skills, both written and oral
  • Ability to conduct internal and external presentations to various groups
  • Ability to develop a network of professionals to benchmark with other Plans or companies to identify and share best practices
  • Knowledge of and experience in audit techniques, process auditing, use of current technology and administration processes
  • Certified Coding Certification, or acquire within 24 months

Equal Opportunity Employer

Blue Cross Blue Shield Association is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, gender identity, disability, veteran status, genetic information or any other legally protected characteristics

Make an impact on healthcare in America. A career with Blue Cross Blue Shield Association allows you to be part of the foundation that supports the 35 Blue Cross and Blue Shield companies nationwide, while protecting and strengthening the Blue Cross Blue Shield brand. Our work is helping provide greater access to cost-effective healthcare, improve the health of America and build stronger communities. With a commitment to diversity, equity and inclusion, we celebrate different cultures, languages, backgrounds and experiences while striving to advance health equity, and we want you to join Team BCBSA.

Accommodations:
Vision Accommodations, Hearing Accommodations, Neurodiversity, Learning, Mental Health, Mobility