Senior Discovery Business Analyst

Company: Accident Fund Insurance Company of America ( Learn More )

General Information
US-MI-Detroit
N/A
Not Specified
Full-Time
Not Specified
Not Specified
False
False
Job Description COBXCOBX Recoveries & SurveysSUMMARY

Identifies and develops approaches to pursue claims overpayment opportunities. Tests and qualifies hypotheses using extracted data. Validates findings and develops communication plans in conjunction with other business areas and governance bodies.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  1. Designs, develops and documents objective approaches to investigate, analyze and pursue claims overpayment hypotheses.
  2. Continually identifies and pursues new, unique claims overpayment hypotheses in order to achieve savings targets.
  3. Develops and refines high-level data queries in order to find trends and recovery opportunities.
  4. Develops audit questions to identify overpayments and root causes.
  5. Quantifies audit results, size opportunities and estimated recovery savings. Maximizes accuracy of savings estimates.
  6. Locates applicable CMS and/or internal policies to validate claims overpayment hypotheses.
  7. Validates findings with other business units and governance bodies.
  8. Perform other related duties as assigned.

EDUCATION AND/OR EXPERIENCE

  1. High school graduate or GED equivalent required. Bachelor's degree in related field preferred.
  2. Two (2) to five (5) years of experience in related field.
  3. Prior claims audit experience preferred.
  4. Prior claims processing experience preferred.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES

  1. Knowledge of Medicare Advantage plan operations.
  2. Strong analytical, reasoning and critical thinking skills.
  3. Strong working knowledge of claims operations including knowledge of coordination of benefits (COB) claims process flows for medical/surgical, DME, and pharmaceutical vendors.
  4. Strong working knowledge of Microsoft Access, other Microsoft office applications, and related software programs.
  5. Ability to effectively communicate data results and overall findings to analysis team, other operations and recovery staff , other business areas and governance bodies as needed.
  6. Knowledge of related laws, legal codes, government regulations and applicable CMS policy.
  7. Other related skills and/or abilities may be required to perform this job.

LANGUAGE SKILLS

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS

Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

REASONING ABILITY

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include distance vision, color vision, and ability to adjust focus

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually quiet.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Job Requirements

EDUCATION AND/OR EXPERIENCE

  1. High school graduate or GED equivalent required. Bachelor's degree in related field preferred.
  2. Two (2) to five (5) years of experience in related field.
  3. Prior claims audit experience preferred.
  4. Prior claims processing experience preferred.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.