LTHC

Analyst

• Perform technical services within the actuarial or risk adjustment department supporting Health Plan operations and financial solvency
• Monitor current data and environments and model future events
• Interact with internal and external partners and regulatory agencies
• Monitor trends and communicate opportunities and data insights
• Provide statistical information and analysis to support informed leadership decisions
• Develop and maintain analyses related to benefit designs, claims experience, Value Based Payment programs, claims savings, and risk adjustment initiatives
• Maintain reserve programs, pricing files, benefit relativity tables, trend and risk score analyses, VBP and vendor financial settlements, and ROI work
• Create and maintain technical and process documentation, data models, data mapping, and training materials
• Develop financial, claims, risk score, trend, utilization, and savings projections and unpaid claim liability estimates
• Compile and analyze data, support data quality, and provide recommendations
• Improve processes using system and software applications
• Reconcile Data Warehouse data with corporate financials or encounter submissions and develop corrective actions
• Lead or support projects, process improvements, reporting, dashboards, and strategic initiatives
• Conduct exploratory, descriptive, and inferential analysis using statistical and machine learning techniques
• Interpret regulatory changes and develop impact analyses for the Health Plan
• Collaborate with departments, stakeholders, senior leadership, and external constituents
• Travel across the Health Plan service region for meetings and/or trainings as needed

Healthcare Statistical Analyst I – IV, VBP

IT Support

• Install, configure, troubleshoot, patch, and maintain enterprise software platforms
• Conduct application testing, systems troubleshooting, performance optimization, and maintenance
• Monitor system uptime and performance
• Maintain system configuration and application backups to ensure recoverability
• Manage user and system accounts, network rights, and access to integrated systems
• Collaborate with cross-functional teams, developers, QA personnel, business teams, internal teams, and vendors to resolve incidents
• Document ticket resolutions and root cause analyses
• Analyze operational procedures, identify and escalate issues, and create effective resolutions
• Maintain documentation and provide release documentation feedback
• Participate in on-call production support, including off-hours
• Identify system risks and recommend growth, improvement, upgrade, and technology strategies
• Act as a subject matter expert and determine business requirements for supported applications
• Coordinate with vendors and assess application release impacts
• Define and implement application security processes and organizational standards
• Mentor team members and provide technical support on complex application issues
• Lead meetings, develop training and process documentation, and facilitate presentations
• Advise leadership and lead business-critical application projects and strategic efforts
• Optimize technology costs when designing and recommending solutions

IT Platform Admin I – IV

Reviewer

• Coordinate, integrate, and monitor utilization of behavioral health or physical health services for members
• Perform pre-service, concurrent, and post-service clinical reviews to determine appropriateness and medical necessity of requested services
• Apply clinical review criteria, guidelines, medical policies, contractual benefits, and State and Federal Mandates
• Plan, implement, and document utilization management activities
• Obtain clinical information from members and providers and interact with treating physicians and other care providers
• Refer appropriate cases and potential quality-of-care or utilization issues to the Medical Director
• Collaborate with hospitals, home care, care management, and other providers to prevent gaps in care
• Act as a resource and liaison to the provider community
• Perform pricing, coding, and claims research when assigned
• Meet departmental timeliness, production, metrics, audit, regulatory, and accreditation requirements
• Assist with training and special projects
• Participate in rotating on-call schedules and work additional hours as needed
• Level II: suggest process improvements, mentor staff, manage complex assignments, and participate in committees
• Level III: provide leadership, resolve escalated issues, update procedures, mentor staff, support orientation and training, and provide supervisor backup

Utilization Management Reviewer, RN

Data Analyst

• Develops ongoing knowledge of Health Plans tools and data sources/structures (i.e. Enterprise Data Warehouse (EDW) and/or Medical/Pharmacy Management systems) to accurately pull data.
• Independently seeks to understand the business/programs and partners at the Health Plan to better understand the business requirements (the ‘why’) of the request and applies both knowledge of the business and analytic skills to proactively fulfill request.
• Prepares, develops, analyzes, shapes and delivers reports in an accurate and timely manner that ‘tell a story’ including but not limited to health plan cost and utilization trends, monitoring effectiveness of care management programs, clinical variation and data mining to find potential opportunities to better control costs and utilization, as needed.
• Compiles complex data sets and simplify/tailor according to audience delivering analyses to.
• Evaluates and processes raw data for user friendly and provides actionable insight (visual and otherwise) to end users.
• Collaborates with team members, leveraging skill sets across the team and aiding in growth and development as needed.
• Proactively problem solves, investigates and tactfully brings forward concerns to management and/or business partners with relation to data pulls and analyses, as appropriate.
• Uses Health Plan defined populations and appropriate analytic tools to pull data set to identify membership (at the highest level) for downstream data analysis of claims, care management programs, etc.
• Partners with other specialized analytic units (i.e. Business Intelligence) to develop automated production reports, dashboards and cubes for efficiency when appropriate.
• Builds collaborative relationship across functional teams and other analytic teams across the organization.
• Manages, organizes and prioritizes tasks for multiple projects with competing deadlines to successful completion.

Healthcare Statistical Analyst I – IV, VBP

IT Platform Admin I – IV

Utilization Management Reviewer, RN

Healthcare Data Analyst