Job Description

Serves as a strategic analytics partner to the Special Investigations Unit (SIU) and Payment Integrity teams by delivering actionable business intelligence, financial reporting, operational insights, and statistically sound audit support. This role combines advanced data analysis, dashboard development, healthcare claims expertise, and stakeholder engagement to identify fraud, waste, abuse, payment accuracy opportunities, and operational improvement initiatives.

The analyst develops reporting and analytical solutions that support provider investigations, overpayment recovery efforts, prepayment and post-payment audit programs, and executive decision-making. This role is responsible for translating complex healthcare data into meaningful insights, measuring program effectiveness, supporting statistically valid sampling methodologies, and driving measurable savings and operational efficiencies across the organization.

• Partner with Special Investigations Unit (SIU), Payment Integrity, Clinical, Finance, and operational stakeholders to identify business needs and develop analytical solutions that support fraud, waste, abuse detection, payment accuracy, and operational performance management.
• Design, develop, and maintain dashboards, scorecards, reports, and self-service analytics solutions that provide actionable insights into investigation outcomes, provider risk, savings, recoveries, cost avoidance, inventory management, and key performance indicators.
• Analyze healthcare claims, provider, member, audit, and investigation data to identify trends, anomalies, emerging risks, and opportunities for financial and operational improvement.
• Develop recurring and ad hoc financial and operational reporting used by leadership to measure program effectiveness, resource utilization, productivity, return on investment, and strategic objectives.
• Design, execute, validate, and document statistically valid random sampling methodologies to support provider audits, overpayment identification, error rate measurement, and extrapolation activities.
• Collaborate with business partners, BI Analysts, Data Scientists, and others to define data requirements, improve data quality, and operationalize advanced analytical solutions.
• Facilitate requirements gathering, solution design, and stakeholder review sessions to ensure reporting and analytical solutions meet business objectives and deliver measurable value.
• Validate data accuracy, reconcile reporting outputs, and ensure consistency of financial, operational, and analytical metrics across multiple systems and audiences.
• Communicate analytical findings, insights, risks, and recommendations to business partners and leadership through effective visualizations, presentations, and written summaries.
• Establish and maintain reporting standards, documentation, governance practices, and development methodologies to ensure scalable, reliable, and sustainable analytical solutions.
• Manage multiple projects and priorities simultaneously while proactively communicating status, risks, dependencies, and opportunities to stakeholders and leadership.