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Position Summary:

This person will identify fraudulent provider/member activity and develop cases to refer to the Investigations or prepayment team.

This position reports directly to the Data Science Fraud Manager and assists in the development of investigation targets, proposes new methods of data analytics and healthcare informatics to discover Fraud, Waste and Abuse activities as well as provide program-wide trend analysis. The Senior Data Analyst will use advanced analytics, predictive modeling, and proactive data analysis to identify trends and patterns. They will be able to manage multiple tasks and projects simultaneously, establish priorities and own deliverables end to end. This position will also work with a variety of business areas inside and outside of the Law Department in the development and management of corporate initiatives.

Key Accountabilities:

• Identify new and emerging fraud schemes using advanced analytics tools available to FIP.
• Use a data-driven approach to inform decision-making, analyze data solutions and reliability, and identify opportunities for optimization and improvement.
• Understand machine learning concepts and collaborate with data science teams to interpret model outputs and fraud scores.
• Independently generate potential fraud leads for investigation or referral to appropriate internal business areas.
• Apply expertise in data mining, data analysis and the presentation of data to support analytic projects.
• Create reports, insights and analytics in support of the business.
• Partner with cross functional teams to correctly categorize complex data appropriate to the various business areas.
• Identify and make recommendations to management for implementing improvements that minimize or eliminate risks for fraud and improve quality of care for BCBSMA members.
• Contribute to meetings and training sessions including occasionally preparing and delivering PowerPoint Presentations as needed.
• Retrieve and analyze data and present reports to management for use in supporting operational and business objectives.
• Constructs and applies statistical and/or financial models to support strategic initiatives.
• Provide recommendations for improvement and written documentation that relates to the analysis of the data. Research data anomalies and issues.
• Facilitate requests for ad hoc reports required to support investigations.
• Conduct special assignments as needed.

Qualifications (knowledge/skills/abilities/behaviors):

• Proficiency in Excel, Access, Word, PowerPoint and SQL.
• Programming experience in SAS, R, Python, or similar analytical languages preferred.
• Experience with data visualization tools (Tableau, Power BI).
• Knowledge of cloud-based analytics platforms (AWS, Snowflake).
• Understanding of machine learning concepts and algorithms with ability to interpret model outputs
• Ability to analyze and interpret qualitative data (research, feedback) and incorporate such insights into quantitative analyses.
• Experience working with large structured and unstructured data sets.
• Understanding of key topics and literature in health care and applied analytics
• Strong teamwork and ability to solve data and analytic problems through communication and collaboration.
• Knowledge of BCBSMA claims processing system is preferred.
• Proficient analytical and report development skills.
• Excellent written and verbal skills, with the ability to clearly and concisely present issues, analytical planning, and recommendations in verbal, written and presentation formats across all levels of the organization.
• Results orientated with the ability to self direct daily.
• Ability to prioritize projects to meet scheduled deadlines.
• Ability to think logically and process sequentially with a high level of detailed accuracy.
• Ability to analyze complex raw data and identify potential fraud risks.
• Working knowledge of health insurance claims coding, including CPT, HCPCS, ICD-10, and DRG coding. This is an essential requirement of the job.
• Strong organizational and prioritization skills; ability to manage multiple priorities effectively.
• Innovative mindset with proven ability to develop creative solutions

Education/Relevant Experience:

• Bachelor’s degree in a relevant field such as healthcare or data analytics.
• Advanced degree in relevant field (Analytics, Healthcare Administration, Statistics, or a related field) preferred.
• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar fraud detection/healthcare certification preferred.
• At least five years business experience.
• Skilled at manipulating and analyzing large data sets.
• Four years’ experience in investigation/detection, data analytics or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions.

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Time Type

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.