This position provides independent analysis and creates presentations and reports to support the needs of the Clinical Operations Department, which is responsible for care management, utilization management, and other medical management functions. Responsibilities include development of reports that will enable more efficient workflows and processes for department staff, as well as reports that will optimize the way that leadership will be able to monitor, assess, and evaluate departmental performance and member outcomes. Additionally, this role will provide analytical support to senior leadership related to the identification of new opportunities that would positively impact quality performance and reduction of inappropriate utilization/ medical spend.
Essential Functions and Responsibilities
- Aggregate and interpret operational and utilization data in order to identify populations that would benefit from new programs or interventions, as well as evaluate the effectiveness of clinical programs and/or specific interventions.
- Advise on the development of key performance indicators that appropriately measure process and/or outcome data in order to gauge effectiveness of clinical programs and related initiatives.
- Leads projects which may involve elements of data analysis and performance improvement to implement system changes. This may also include providing oversight, change management, general work direction or leadership to individuals on team. Conducts regular meetings with stake holders and share necessary documentation
- Creates presentations and/or reports for department leadership, often involving significant analysis of multiple or complex data sources. Relays information presented in a clear and concise method that easily relay complex information in a way that can be shared with other senior leadership within the organization without additional explanation. Clearly identifies and documents assumptions, findings, limitations, insights, and recommendations.
- Identify trends in data, including those that were not necessarily being activity monitored, which may have an impact on departmental performance and/or member outcomes. Communicate actionable findings and provide recommendations as appropriate to management.
- Strengthen management’s understanding of key drivers of medical cost in order to inform them of new operational processes.
- Learn relevant departmental operations (i.e., case management, utilization management, and other department responsibilities). Ensure understanding of staff responsibilities, barriers to success, and management’s performance expectations in order to inform and advise appropriately and comprehensively.
- Design elegant solutions to automate department procedures using appropriate software such as Microsoft Access databases, Microsoft Excel spreadsheets/ macros, SQL and/or SAS. Work directly with managers and subject matter experts to refine and improve these tools for optimal efficiency and effectiveness.
- Developing various "impact" and "scenario" models to assess financial exposure based on changes to business and contractual methodologies.
- Perform mathematical, quantitative, or qualitative analysis for special projects that may arise on an ad-hoc basis.
- Responsible for and/or participates in creating data definitions, validating data, retrieving data from systems, merging data from multiple sources, participating or reviewing technical documentation, report configuration, creating training materials and facilitating or leading cross functional teams through projects and/or issues to achieve desired results.
- Performs analysis of internal and/or external customer needs. Manages and Supports the identification and research of new developments and uses of current systems and applications, as well as upgraded systems and applications to meet these needs. Data may include, but are not limited to; online applications, electronic forms, moderate to complex reports.
- Serves as an expert resource for displaying of data in reporting, and maintains optimal operation of departmental reports in partnership with IT or external software vendor, as appropriate. This may include leading the implementation, maintenance, testing and/or functional design.
- Job performance requires fulfilling other incidental or related duties as assigned, assisting and training others, and performing duties of higher rated positions from time to time for developmental purposes.
Educational and Experience Requirements
Work Related Experience:
- Five or more years of analytical experience required. Analytical experience in managed care and/or other healthcare setting strongly preferred.
- Proficiency in Microsoft Office, including VBA (Visual Basic for Applications) programming, and either SQL and/or SAS.
- Demonstrated ability to work independently within set timeframes without a large amount of oversight
- Must have strong analytical and problem solving skills.
- Strong organizational skills, as well as excellent oral and written communication and human relation skills, are required.
- Familiarity with claims / encounter data, as well as Medicare / NY State Medicaid reimbursement methodologies preferred
- Knowledge of HEDIS/QARR quality measure methodology preferred.
- Experience with Facets, Clinical Care Advance, or other case management, utilization management, and/or claims information systems a plus
Education, License, and Certification Requirements
- BA/BS - Bachelor's Degree in mathematics, statistics, economics, actuarial science, computer science, or a related business discipline, required.
- Master’s degree in a related field strongly preferred, but will also consider candidates with other related education and/or experience in lieu of master’s degree.