Manager, Claims Analytics

Profile

We offer remote work opportunities for those residing in the following states ONLY:

AZ, AK, AR, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, WA, WI, WY

This position will operate on Arizona Time (Mountain Standard Time)

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

This role manages healthcare data reporting, querying, and analysis for the Data Management department with direct responsibility for reports, metrics, trending, and forecasting for Claims Administration and Finance. Oversees a team of Business Intelligence Analysts and BI Developers tasked with providing TriWest leadership with insights from claims, operational, and performance data. Monitors performance on operational performance and identifies opportunities to improve. Evaluates utilization patterns and develops analysis with recommendations to optimize claims processing to better complement the Government healthcare system and help TriWest meet goals related to access to care and budget targets. Supports strategic initiatives related to healthcare cost management performance objectives and contractual reporting. Drives the organization towards data-driven decision making.

Education & Experience

Required:

• Bachelor's degree in Business Administration, Healthcare, Statistics, Information Management, CIS or related field or equivalent experience
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 5+ years of data analysis and reporting experience in the health care or insurance industry, with 3+ years dealing with medical, pharmacy and ancillary claims data, membership data or other healthcare data
• 3+ years experience leading/managing reporting and analytics teams
• Advanced knowledge of Business Intelligence tools (e.g. PowerBI, Tableau)
• Excellent verbal and written communication skills and an ability to synthesize and present results in a clear and concise manner
• Demonstrated proficiency in the use of SQL query language
  
  

Preferred

• Familiar with coding methods and guidelines (CPT, ICD, HCPCS, POS, DRG, Revenue)
• 3+ years developing clinical measures and analyzing healthcare outcomes
• 1 year of experience with advanced analytics tools (e.g. Python, R)
• Masters degree in Business Administration, Statistics, Public Health or other applicable discipline
• Experience with VA healthcare, military health services system, and private Managed Care programs
  
  

Key Responsibilities

• Act as an internal consultant to work across key stakeholders to gather data, perform analysis, and provide recommendations and insights to business leaders.
• Familiar with coding methods and guidelines (CPT, ICD, HCPCS, POS, DRG, Revenue).
• Execute business reporting functions, metric creation and reports that demonstrably drive operational actions and highlight wins / opportunities.
• Interpret claim data using a variety of techniques, ranging from simple data aggregation via statistical analysis to complex data mining.
• Drive improvements in cost efficiency, quality of clinical care, and effectiveness of clinical programs by performing data analysis to deliver actionable insights that are backed by empirical evidence.
• Develop optimization analysis to determine how well TriWest's network meets the needs of the Government based on authorization/claims patterns, discounts achieved and access to care requirements.
• Collect, compile, and analyze healthcare cost and discount trends, and identify opportunities for improving/maintaining discounts based on utilization patterns.
• Collaborate with others in Data Management and IT to enhance the data warehouse to include translating technical and functional requirements into meaningful information and improve healthcare reporting capability.
• Train department staff on healthcare data querying, terminology, integrity, standards, and procedures.
• Coach and mentor staff toward operational excellence and skill development.
• Work with management to understand and interpret the impact of decisions made by retrieving and analyzing claims costs, authorizations and/or other relevant data. Work closely with various groups in the assembling of data, development and application of quantitative analysis and mathematical models for internal and regulatory reporting requirements.
• Support Government reporting requirements, management and the medical management system by managing automated reports.
• Develop methods for consistency and validity and review the accuracy of data and reports. Determine the best approach for presenting data in an efficient and beneficial manner.
• Preparation of annual performance evaluations and development plans for assigned staff.
• Perform other duties as assigned.
• Regular and reliable attendance is required.
  
  

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Strong knowledge of Microsoft Excel, Access, Preferred strong knowledge of Crystal Reports, SQL Reporting Services, and other query software; knowledge of relational databases; working knowledge of medical management systems; working knowledge of referral and authorization systems; working knowledge of healthcare; working knowledge of medical coding, HIPAA regulations, claims processing, and healthcare reimbursement systems.

Working Conditions

Working Conditions

• Works within a standard office environment with minimal travel
• Extensive computer work with prolonged sitting
  
  

Company Overview

Taking Care of Our Nation’s Heroes.

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Generous paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time
  
  

*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $125,000- $142,000 depending on experience*

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.