Detailed Description:
* This position is responsible for developing, implementing, and validating utilization and cost models which characterize providers' claims submissions and treatment patterns. Additional responsibilities include determining if dentists are meeting the terms of participation in provider networks throughout the Enterprise and gathering and analyzing data from Enterprise repositories for recruitment purposes.
* Performs queries, maintains integrity of databases and repositories and collects data to be used for ad-hoc request reports and documentation.
* Prepares compensation reports and actuarial requests for compensation comparisons and analysis for compensation review committee meetings.
* Reviews and prepares reports, compiles statistics, and analyzes data regarding dentists that are requesting to have changes made to their compensation.
* Coordinates collection of internal data to facilitate investigation of irregularities by dentists, enrollees or other external entities, and respond to inquiries from internal investigative requests from compliance or legal.
* Assists with onsite investigations into cases of suspected fraud or misrepresentation involving providers, brokers, clients or enrollees by collecting and providing the necessary data and statistics.
* Keeps abreast of network infrastructure and leverages data sets needed to meet Enterprise business requirements.
* Reviews profiling parameters for statistical validity and recommend adjustments.
* Supports Client Acceptance Testing of Enterprise approved business applications and provides input to improve reliability and accuracy of data.
* Trouble shoots and suggests improvements to systems and software applications.
* Builds, develops and tests applicability of new utilization models based on claims data from MetaVance and evaluates systems and develops processes to streamline procedures.
* Serves as a technical resource to division employees and coordinates with all other Enterprise areas when applicable.
Job Requirements:
* Bachelor's degree or equivalent education is preferred, but candidates with proven experience will not be excluded from consideration.
* A minimum of 3 years' experience in business, data collection/coordination and analysis in areas of investigation and/or claims review processing.
* Detail oriented with research, analytical and problem-solving abilities.
* Knowledge and application of English grammar including composition, editing, proofreading and strong verbal communication skills.
* Strong organizational/time management and project management skills and multi-tasking abilities.
* Basic knowledge of generally accepted accounting principles.
* Strong mathematical skills and ability to perform complex statistical calculations.
* Knowledge of health care industry issues is preferred.
* Knowledge of Enterprise products, policies, claims, eligibility and underwriting guidelines and procedures.
* Knowledge of Enterprise systems including, but not limited to Business Objects, MetaVance, AS400 and reporting tools used to generate provider data and reports is preferred.
* PC literacy required; MSOffice skills (Outlook, Word, Excel, PowerPoint and Access) and knowledge of other Enterprise analytical systems.
* Regularly required to operate standard office equipment (personal computer, photocopy machine, fax machine, etc.).
* Ability to work on a computer up to 7 hours a day.
* Regularly required to sit for long periods of time, and occasionally stand and walk.
* Regularly required to use hands to operate computer and other office equipment.
* Close vision required for computer usage. Occasionally required to stoop, kneel, climb and lift up to 25 pounds.
* Ability to travel. Must possess valid driver's license and be able to drive a motor vehicle.
* Ability to clearly present written information and findings. Ability to communicate concepts.
* Ability to make executive-level presentations. Ability to interact well with co-workers and outside contacts.
