Lead Clinical Data Consultant (Part-time, Remote)

30 hours per week

In this role the Lead Inpatient Data Analyst will provide subject matter expertise in support of analyzing Medicare inpatient claims data to develop comparative billing reports and programs to evaluate payment patterns electronic reports. The Lead Inpatient Data Analyst will also have to conduct research of report and target development in support of Medicare fee-for-service claims data analysis. The Lead Inpatient Data Analyst may coordinate with CMS and other stakeholders for report support and education.

Job Responsibilities:

• Assist in the development of comparative billing reports (CBR) and programs to evaluate payment patterns electronic reports (PEPPER) reports in support of CMSs effort to reduce Medicare fee-for-service improper payments.

• Uses data science techniques to perform and review tasks such as:

1. Data Analysis on large data sets
2. Data Mining
3. Statistical Analysis and
4. Text Mining

• Participate in the evaluation of target areas for all PEPPER types providing recommendations for discontinuation or identifying new target areas that could benefit specific facility types.

• Conduct claims data analysis to assist in the development of PEPPER reports targeted to physicians suppliers pharmacies and other medical professionals.

• Conduct research to support topic development and work with the data analytics staff in creating report metrics.

• Assist with analyzing outlier data to identify target patterns other anomalous patterns and report findings as well as support ad-hoc reports and special studies as needed.

• Develops and reviews models using machine learning techniques.

• Applies Natural Language Processing (NLP) and Artificial Intelligence (AI) frameworks to address business challenges and support data-driven decision-making.

• Continuously learning (staying up-to-date) Medicare policy changes and updates.

• Support the development of educational materials and activities (webinars conference calls) to support CMS stakeholders and other contractors in using the report data.

• Support the ongoing review and updates of all PEPPER User Guides and related documentation across all PEPPER types.

• Support CMS and other contractors with provider questions related to report findings.

• Attends meetings trainings and conferences as needed or available

• Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective consistent and professional manner.

• Able to maintain quality and meet expectations.

• May provide subject matter expertise in areas of clinical nursing quality education mentoring or peer reviews.

• Maintains strict confidentiality and security of all sensitive and/or business confidential information obtained or accessed during the course of business and/or contract operations.

• Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.
• Adheres to applicable policies and procedures ensuring commitment to quality compliance and security to protect the confidentiality integrity and availability of sensitive data and information.
• Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based) whether on an annual or ad/hoc basis.
• Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective consistent and professional manner.

Job Qualifications:

• Bachelors Degree in nursing statistics mathematics computer science or related field or possesses a minimum of 4 years data analysis experience within the healthcare industry.

• Experience in reviewing Medicare and Medicaid claims for appropriate billing and medical coding requirements performing medical review and/or developing fraud cases.

• Demonstrated proficiency in medical review work.
• Strong analytic and research skills.
• Preferred working knowledge of Medicare and/or Medicaid programs.
• Knowledge of medical terminology ICD-9-CM ICD-10-CM HCPCS level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations.

• Knowledge of analytic methodologies and principles.
• Responds to tasks or requests in a cooperative and timely manner.
• Demonstrates adaptability to change and initiates or identifies change when necessary.
• Strong customer service organizational analytical skills.
• Demonstrates strong proficiency in oral and written communication interpersonal relations and organizational effectiveness.

• Ability to take initiative to maintain confidentiality to meet deadlines and to work in a team environment.

• Ability to handle confidential material.
• Ability to work independently and as a member of a team to deliver high quality work.
• Ability to multitask and prioritize assignments while meeting deadlines.

• Proficiency in Microsoft Office products such as Excel Word PowerPoint and Outlook.
• Passion and alignment with IntegrityMs mission vision values and operating principles.
• Must pass post hire background screening checks.
• For remote work required to have wired and/or wireless internet access.
• Ability to obtain security clearance if requested by Client/Contract.

Preferred Qualifications:

• Current Registered Nurse (RN) license or equivalent or higher degree and licensure in the medical field 3 years of clinical experience as a Registered Nurse or other clinician and/or experience in review of medical claims for coverage and medical necessity.
• Knowledge of CMS rules regulations NCDs LCDs and other guidance.
• Certified Professional Coder (CPC) certification or equivalent.

Required Experience:

Contract