Duties Description The Data Analyst 3 will work within the Bureau of Federal Systems, Funding, & Compliance in the Office of Health Insurance Programs. The incumbent will lead a unit focused on federal data compliance, pharmacy claims integrity, fee-for-service encounter analysis, and support of audit and data investigations initiated by the Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG). This position serves as the technical and analytic lead for ensuring Medicaid claims and encounter data meets federal reporting standards, identifying pharmacy fraud, waste, and abuse through advanced analytics, investigating fee-for-service claims and encounter anomalies with deep understanding of Medicaid rate code structures and reimbursement methodologies, and providing data, documentation, and analytic support in response to federal audit inquiries and compliance reviews.
The incumbent will perform the most complex data analysis activities, including evaluating pharmacy claims for aberrant prescribing patterns, drug diversion schemes, controlled substance anomalies, and non-compliant billing against Medicaid fee schedules and rate codes. This position is responsible for ensuring data submitted to CMS -and other federally mandated reporting - is accurate, complete, and timely, and that all data quality issues impacting federal compliance are identified, investigated, and resolved. The incumbent also serves as a primary analytic resource for audit data investigations from CMS and OIG, producing responsive data extracts, conducting investigative analyses, preparing audit documentation, and coordinating with program areas to address findings and corrective action plans. The incumbent combines advanced technical expertise in data analysis, SQL, business intelligence tools, and statistical methods with comprehensive knowledge of Medicaid rate codes, fee-for-service reimbursement structures, pharmacy benefit administration, federal data reporting requirements, and federal audit processes to analyze complex claims relationships, identify compliance gaps, and develop corrective action strategies. Excellent analytical and communication skills, demonstrated expertise in claims data analysis, knowledge of Medicaid rate code structures and fee-for-service billing rules, federal Medicaid reporting requirements, pharmacy claims adjudication processes, and experience supporting federal audits and compliance reviews is required. Previous experience leading analytic teams, working with large-scale healthcare datasets, and ensuring federal compliance in Medicaid programs is required.
Specific duties include, but are not limited to:
• Lead and direct the activities of a unit dedicated to federal data compliance, pharmacy fraud/waste/abuse detection, fee-for-service claims analysis, and audit data support; establish unit goals, priorities, and operational procedures; provide technical guidance and mentorship to unit staff on claims analytics, rate code interpretation, federal reporting standards, pharmacy data analysis, and audit response protocols;
Conduct the most complex analyses of pharmacy claims data to identify fraud, waste, and abuse indicators including aberrant prescribing patterns, excessive dispensing volumes, controlled substance diversion, therapeutic duplication, inappropriate days-supply manipulation, pharmacy shopping behaviors, and billing for non-covered or excluded drugs against Medicaid formulary and fee schedule rules;
Analyze fee-for-service claims and encounter data to identify billing irregularities, rate code misapplication, pricing discrepancies, unbundling, upcoding, and reimbursement anomalies; apply deep knowledge of Medicaid rate code structures - including APGs, DRGs, fee schedule methodologies, and service-specific reimbursement rules - to validate claims accuracy and identify systemic billing errors;
Serve as an analytic resource for audit data investigations from CMS and OIG; produce responsive data extracts, conduct targeted investigative analyses, prepare audit documentation and data validation packages, reconcile discrepancies identified by federal auditors, and coordinate with program areas and fiscal staff to develop and track corrective action plans;
Oversee the analysis and validation of data submitted to CMS for federal reporting including; identify data quality deficiencies, develop root cause analyses, and coordinate corrective actions to maintain compliance with CMS data quality thresholds and avoid federal funding penalties;
Develop and maintain data quality monitoring frameworks that track completeness, accuracy, timeliness, and consistency of claims, encounter, and pharmacy data against federal standards; produce recurring compliance scorecards and alert management to emerging risks, CMS certification outcomes, or audit readiness;
Investigate fee-for-service encounter submission issues including missing or rejected claims, edit/audit failures, provider enrollment discrepancies, and rate code mapping errors; coordinate with claims processing (eMedNY), pharmacy benefit systems, and managed care encounter intake processes to resolve systemic data issues;
Research and interpret federal Medicaid regulations, CMS guidance, State Plan Amendments, and policy changes impacting rate code structures, pharmacy benefit rules, federal data reporting requirements, and audit methodologies; assess the analytic and data quality implications of regulatory changes and recommend system or process modifications;
Develop and implement advanced analytic methodologies - including statistical outlier detection, trend analysis, peer comparison models, and risk scoring - to prioritize pharmacy FWA investigations and fee-for-service claims reviews; produce actionable intelligence and referral packages for program integrity staff;
Develop and maintain compliance dashboards, reporting tools, and analytic products that enable federal reporting staff, program integrity units, audit response teams, and management to monitor pharmacy claims trends, fee-for-service anomalies, , audit finding status,
Review data sources, analytic products, and reports produced by lower-level staff for accuracy, completeness, and alignment with federal standards; coordinate trend analysis across pharmacy and fee-for-service claims data; oversee the drafting of informational documents on compliance methodologies, audit responses, and findings; and review and recommend improvements to current analytic processes and systems;
Perform the full range of supervisory responsibilities over Data Analysts and technical staff within the unit
Minimum Qualifications Non-competitive: nine years of experience* in data visualization, and statistical models and data mining tools.
*Substitution: An associate's degree may substitute for two years of general experience; or a bachelor's degree may substitute for four years of general experience. A master's degree in data or computer science, informatics, economics, statistics, mathematics, or a related field, may substitute for one year of general experience; or a Ph.D. in these fields may substitute for two years of general experience.
Preferred Qualifications: Professional experience in Information Technology, data analysis and management (e.g., database design, database optimization, transformation and load activities, query design and optimization, and experience with large-scale multi-tier/multi environment databases), and experience in a health-related information technology program; Demonstrated strong analytical, organizational, reporting and communication abilities. Moreover, the desired candidate should be experienced with and capable of contributing, as an analytics subject matter expert, to a large group of stakeholders. The preferred candidate will have the ability to independently develop strategies to ensure program integrity and aid in identifying opportunities for improvement to eliminate waste, fraud or abuse of activities which could be occurring in the administration of the Medicaid program.
Additional Comments When reviewing qualifications, omissions and vagueness cannot be interpreted in the candidate's favor. Candidates are responsible for providing accurate and clear descriptions of their experience demonstrating how they meet the minimum qualifications.
We offer a work-life balance and a generous benefits package, worth 65% of salary, including:
• Holiday & Paid Time Off
• Public Service Loan Forgiveness (PSLF)
• Pension from New York State Employees' Retirement System
• Shift & Geographic pay differentials
• Affordable Health Care options
• Family dental and vision benefits at no additional cost
• NYS Deferred Compensation plan
• Access to NY 529 and NY ABLE College Savings Programs, and U.S. Savings Bonds
• And many more...
Name Human Resources Management Group, EW/DA3/90606
Fax 518-473-3395
Email Address resume@health.ny.gov
Address
Street Corning Tower, Empire State Plaza, Room 2217
City Albany
State NY
Zip Code 12237
Notes on Applying Please submit your resume and cover letter as one (1) document, preferably in PDF format, by email to resume@health.ny.gov, with Reference EW/DA3/90606 included in the subject line or by mail to Human Resources Management Group, EW/DA3/90606, Rm 2217, Corning Tower Building, Empire State Plaza, Albany, NY 12237-0012, or by fax to (518) 473-3395. Failure to include the required information may result in your resume not being considered for this position.
