Integrity Management Services, Inc.

Lead Clinical Data Consultant

Integrity Management Services, Inc.

part-time

Posted on:

Location Type: Remote

Location: Remote • Virginia • 🇺🇸 United States

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Job Level

Senior

About the role

  • Assist in the development of comparative billing reports (CBR) and programs to evaluate payment patterns electronic reports (PEPPER) reports in support of CMS’s effort to reduce Medicare fee-for-service improper payments.
  • Uses data science techniques to perform and review tasks such as:
  • Data Analysis on large data sets
  • Data Mining
  • Statistical Analysis, and
  • 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.

Requirements

  • Bachelor’s 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 IntegrityM’s 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.

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard skills
data analysisdata miningstatistical analysistext miningmachine learningnatural language processingartificial intelligencemedical codingICD-9-CMICD-10-CM
Soft skills
analytical skillsresearch skillscustomer serviceorganizational skillsoral communicationwritten communicationinterpersonal relationsadaptabilityinitiativeconfidentiality