HealthCare Analytics Director
HealthCare Analytics Director
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$ 160000 - 175000
1 Vacancy
Job Description
As a HealthCare Analytics Director ( Payment Integrity) within a payer organization you will serve as a senior-level analytics expert responsible for leading the design and implementation of advanced analytics solutions that support claim accuracy payment integrity fraud prevention and cost containment initiatives. This position plays a critical role in helping the health plan safeguard its financial integrity by leveraging data to identify improper payments and optimize audit and recovery strategies.
Key Responsibilities
- Lead High-Impact Analytics Projects:
- Independently design and execute advanced analytical initiatives to detect overpayments claim anomalies and wasteful billing practices across medical pharmacy behavioral and ancillary services.
- Collaborate Cross-Functionally:
- Partner with internal teams such as SIU Medical Management Provider Audit Finance and Claims Operations to operationalize analytics outputs into actionable payment integrity programs.
- Develop Data Models and Analytics:
- Use advanced knowledge to build models and analytics to flag high-risk claims and support prepayment and post-payment integrity strategies.
- Inform Strategy and Policy:
- Provide insights and thought leadership that shape policy changes provider education and system configuration to reduce future overpayments.
- Evaluate Vendors and Interventions:
- Assess vendor-reported recovery opportunities and validate performance; support ROI tracking vendor scoring and identification of gaps in recovery streams.
- Create Executive Reporting
- Prepare presentations and visual summaries for senior leadership detailing financial impact risk areas trends and emerging opportunities in cost containment.
- Mentorship and Guidance:
- Serve as a mentor to analysts and consultants across the Payment Integrity Analytics team helping drive best practices in healthcare data analysis.
- This position performs other duties as assigned
Required Qualifications
- Bachelors degree in Statistics Data Science Public Health Health Informatics or a related field.
- Minimum 8 years of experience in healthcare data analytics with at least 35 years in a payer-side payment integrity claims audit or SIU function.
- Proficiency in SQL and Python or R; experience working with large-scale claims databases.
- Deep understanding of healthcare claims processing medical coding (ICD-10 CPT HCPCS) DRG validation and NCCI/CES edits.
- Proven ability to lead projects independently synthesize complex data and
communicate actionable insights to senior stakeholders.
Preferred Qualifications
- Masters degree in a quantitative or healthcare discipline.
- Experience leading/building new advanced analytic solutions in a healthcare or health payer company.
- Experience with enterprise platforms such as Optum CES Cotiviti HealthEdge or similar claim editing/audit solutions.
- Familiarity with CMS and commercial plan payment rules FWA regulatory compliance and NCQA/HEDIS standards.
Required Experience:
Director
Employment Type
Full-Time
