Senior Manager MPPS Policy Business Analytics

CVS Health is building a world of health around every individual, seeking a Senior Manager MPPS Policy Business Analytics to develop and automate reports tracking medical and payment policies. The role focuses on delivering data-driven insights to optimize business processes and ensure compliance with policies.

Responsibilities:

• Extract, validate, and interpret large datasets from healthcare claims, authorizations, and payment systems
• Conduct exploratory data analysis to identify patterns, trends, and deviations in payment or utilization
• Evaluate medical and payment policy operations, identifying trends, patterns, and variances related to:
• Medical cost drivers and utilization patterns
• Analyze effectiveness of medical and pre-payment policies, and precertification for delivery of insights on performance to leadership
• Operational efficiency metrics, such as turnaround times and productivity
• Policy compliance and adherence to regulatory requirements
• Review payment policies and procedures for accuracy, identifying gaps and potential inaccuracies
• Ensure adherence to medical policies and regulatory requirements, such as federal and state legislation and HIPAA
• Participate in the design and deployment of algorithms or automated edits to ensure correct payment and prevent overpayments
• Collaborate with stakeholders to gather business requirements for new systems and process improvements
• Translate complex analytical findings and business needs into clear documentation and actionable strategies
• Provide training and ongoing support to end-users on new systems, processes, and analytical tools
• Design, build, and maintain standard and ad-hoc operational reports and interactive dashboards using business intelligence tools (e.g., Power BI, Tableau)
• Collaborate with stakeholders from clinical operations, finance, and other departments to gather business requirements for new reports and analytical projects
• Extract, integrate, and validate data from multiple sources, including claims, membership, and provider data
• Conduct root-cause analysis of data irregularities and ensure data accuracy
• Interpret complex data findings and effectively communicate insights and recommendations to both technical and non-technical audiences through clear visualizations and presentations
• Automate recurring reporting processes and workflows to improve statistical efficiency and free up resources for more complex analysis

Requirements:

• 5-7+ years of experience in a data or business analyst role, preferably within the healthcare or health insurance industry with payment integrity, i.e. medical and payment policies, for executives and decision making
• 2-3 years analyzing claim editing rules for payment accuracy and trends
• Demonstrated proficiency in SQL for querying and manipulating large datasets
• Experience in developing reports and dashboards using data visualization tools like Microsoft Power BI, Tableau and QuickBase Tools
• Experience with claims data, eligibility data, and medical and payment policy analytics
• Knowledge of healthcare industry coding systems, including ICD-10 and CPT
• Familiarity with data governance concepts and data management best practices
• Bachelor's degree in a field such as Finance or Mathematics, or similar field
• Medical coding certification, ie, Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or other certifications preferred