Senior Data Analyst – Clinical CPC-H

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Work area includes development of clinical deterministic/probabilistic rules to identify aberrant billing/Fraudulent patterns in healthcare professional and institutional claims data for UHC all Line of businesses

Development and evaluation of various clinical deterministic & probabilistic rules, data-maps through domain expertise and advanced data mining techniques, identify improvement opportunities resulting in business impact, creating different metrics for clinical rules and innovation or optimization algorithms and building strong relationships with global analytics teams

Significant amount of team and stakeholder management, project delivery, Quality assurance skills in areas like, clinical rule development, validation and data maps development, Rules maintenance, validation and enhancements, exploratory data, and multivariate analysis, improving true positive rate of existing analytics

Positions in this function are responsible for the management and manipulation of mostly structured data, with a focus on building business intelligence tools, conducting analysis to distinguish patterns and recognize trends, performing normalization operations and assuring data quality. Depending on the specific role and business line, example responsibilities in this function could include creating specifications to bring data into a common structure, creating product specifications and models, developing data solutions to support analyses, performing analysis, interpreting results, developing actionable insights and presenting recommendations for use across the company. Roles in this function could partner with stakeholders to understand data requirements and develop tools and models such as segmentation, dashboards, data visualizations, decision aids and business case analysis to support the organization. Other roles involved could include producing and managing the delivery of activity and value analytics to external stakeholders and clients. Team members will typically use business intelligence, data visualization, query, analytic and statistical software to build solutions, perform analysis and interpret data. Positions in this function work on predominately descriptive and regression-based analytics and tend to leverage subject matter expert views in the design of their analytics and algorithms. This function is not intended for employees performing the following work: production of standard or self-service operational reporting, casual inference led (healthcare analytics) or data pattern recognition (data science) analysis; and/or image or unstructured data analysis using sophisticated theoretical frameworks. Generally work is self-directed and not prescribed.

Primary Responsibilities:

• Communicating key analytic findings to client and responsible for addressing client’s analytic concerns
• Communicate clearly and effectively both orally and in writing; conduct meetings and make professional presentations
• Organize and manage time and resources; establish priorities and coordinate work on many projects simultaneously
• Research potential overpayment scenarios through secondary research, seeking to identify overpaid claims used to build recurring algorithms.
• Identify and refine criteria to successfully build and enhance new and existing algorithm logic, ensuring correct claim payment.
• Research and quickly identify patterns of claim payment abnormalities through big data analysis
• Providing both clinical and technical consulting to business leaders at an appropriate level of information encapsulation
• Develop metrics to forecast new algorithm profitability
• Work to gather, examine, and analyze data; write technical specifications for manipulating data to look for Fraudulent patterns
• Identify opportunities, pose business questions, and make valuable discoveries to prototype development and rule improvement. Actively consult with business stakeholders and subject matter experts to ensure appropriate medical and business content is incorporated into analytic approaches
• Be able to work closely with Business Analysts, Domain SMEs to understand business needs and help define requirements for reporting solutions Ability to work closely with onshore and offshore business analysts, Domain SMEs and leads to understand business needs and help define requirements for reporting solutions
• Ensures team gathers right requirements from the business stakeholders and involve in, BI/BRD design and ensure that all specifications are complete, consistent, concise, and achievable,
• Deliver robust and scalable analytic solutions in an automation ready state for payers and provider markets
• Self-drive knowledge accumulation of methods and modeling advances by reading research publications, blogs and attending presentations and webinars
• Works with less structured, more complex issues
• Serves as a resource to others
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• Bachelor’s or higher degree in a related Information Technology field/Healthcare/clinical research
• Medical coding/clinical certification like CPC-H or any other medical certification/knowledge
• 7+ years of experience in conducting research-minded clinical data analysis on variety of healthcare data types/forms with aim to utilize this analysis into building or optimizing clinical solutions; 4+ years of experience in data analytics and claims processes
• Scrum or other Agile development experience
• Data analysis experience
• Experience in research and finding data anomalies, and analysis method with healthcare claims and breaking down and clearly define problems, performing root cause analysis to identify key factors and reasons prompting those factors
• Knowledge of analytical tools and techniques required to perform data analysis. Should have ability to handle/work on medium/large data sets
• In-depth understanding of US healthcare, Payment integrity processes, Claim lifecycle, Adjudication & Pre-Adjudication process (other geographies – UK/Middle East/Indian Healthcare system)
• Demonstrate a solid understanding of project scope, data extraction methodology, design of dependent and profile variables, logic and design of data cleaning, exploratory data analysis
• Proficiency in tools such as Microsoft Office Excel/Access/PowerPoint; Working Knowledge of basic SQL or SAS is required
• Proven solid project management skills, ability to influence cross-functionally in a rapidly evolving business environment while managing multiple / concurrent projects
• Proven ability to communicate ideas effectively and concisely to all levels of Management, business partners, and to other external clients and ability to work independently
• Proven solid analytical, complex thinking, problem solving, and troubleshooting abilities
• Proven excellent written and verbal communication skills
• Proven excellent organizational skills and attention to detail

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.