4+ years of proven analysis experience highly preferred, or 2+ years of proven analysis experience in a healthcare/managed care environment
Bachelors Degree or combination of education and experience
445 Grant Avenue, San Francisco, CA 94108
Brief job information:
Works under the general supervision of the technical lead to investigate business questions and identify improvement opportunities by designing appropriate studies, conducting statistical analysis, and developing reports with healthcare data in areas including utilization, risk management, risk assessment, risk adjustment, Quality Improvement, and cost. Design and maintenance of tools needed for the specific needs of departments.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conducting medical cost and revenue analyses using medical and pharmacy claims and other data sources
- Analysis of medical and pharmacy claims in the appropriate assignment of code including but not limited to two CPT-4, MS-DRG, APR-DRG.
- Analysis and interpretation of RAF scores and HCC’s for both commercial and Medicare models.
- Develop reports and conduct quantitative analysis to understand the trend or issues and to identify the opportunity to improve the quality of care and to manage cost and utilization.
- Skilled in compiling large amounts of data into innovative presentations of information that are clear concise and actionable.
- Ensure the quality of deliverables in terms of the technical design, implementation, testing and adherence to technical compliance standards
- Develop inpatient and when applicable outpatient Episodes of Care for focused “service lines” such as gastroenterology, hematology/oncology, circulatory and other conditions.
- Develop business rules and apply to a strategic plans to recapture health plan costs from high cost providers to quality lower-cost providers.
- Utilize Microsoft Access, SQL, Crystal Reports and other tools to mine database(s) for analytic data.
- Create presentations used by the Medical Management Department, Medical Directors, CEO, CFO and internal and external customers.
- Create and manage all required reporting and analysis that contribute to the overall management and success of the health plan.
- Document analytical approaches and methodology applied.
- Accepts and performs other duties as assigned.
- Bachelor’s Degree or equivalent experience required
- 4+ years of proven analysis experience highly preferred, or 2+ years of proven analysis experience in a healthcare/managed care environment
Skills and Abilities
- Possess the ability to effectively interact with, and present findings to customers at all levels of the organization including operational managers, medical directors and executives required
- Proficiency with MS Access highly preferred
- Proficiency with MS SQL (queries) highly preferred
- Proficiency with MS SQL Server Reporting Services highly preferred
- Proficiency with Crystal Reports highly preferred
- Proficiency with C# programming and design highly preferred
- Clinical code knowledge related to claims/utilization highly preferred
- Experience with managed care contract terms/analysis a plus
- Experience in a Medicare Advantage environment a plus
- Experience in Covered California or other similar exchange environments
- Experience with MS BI products a plus
- Expert skills in MS Office productivity software, especially MS Excel
- Excellent technical, interpersonal, written and oral communication skills required
- Superior analytical skills required
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.
Base Pay Scale: Starting at $65,000 – 97,000 per year
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.