OPEN POSITIONS
Job Summary
Job Type: Independent Contractor
Schedule: Monday – Friday; 15-20 hours per week; Hybrid – two days in the office, three days remote
Work Location: Plano, Texas
Primary Responsibilities:
- Schedule meetings for all company executives
- Coordinate team calendars
- Manage all office and break room supplies
- Organize and coordinate, travel/hotel reservations, meals, preparing agendas and meeting planning
- Organize intro calls and training for new hires
- Answer phones, relay messages and greet visitors
- Set up interviews for new candidates
- Coordinate and support all team members
- Assist with planning and implementing employee recognition activities
- Other administrative duties as assigned
Required qualifications:
- High school diploma or GED
- Administrative experience required: 3+ years
- Microsoft Outlook and Teams experience: 3+ years
- Strong PC knowledge and skills, including all Microsoft Office products: 3+ years
- Must be able to work in a fast-paced environment and have friendly people skills
- Must be able to multitask
- Organized and detail-oriented
- Ability to organize and prioritize work to meet deadlines
- Excellent written and verbal communication skills
- Good judgment, initiative and problem-solving abilities
- Ability to handle and resolve complex issues independently
- Ability to establish and maintain professional, positive and effective work relationships
- Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment
For this position, please apply directly to felavia@smartlightanalytics.com
Summary:
In this role, you will develop analytical models to identify payment anomalies in client’s healthcare claims data (fraud, waste, or abuse). The results from your work will be reviewed by clinical analysts for outcome success. To be successful in the role, you will have sound knowledge and experience Statistical Models, Data Mining, Machine Learning, building analytical solutions to deliver insights, insights communication and presentation, as well as demonstrating the ability to combine advanced analytics skills with exceptional business acumen.
Responsibilities
- Develop a deep understanding of the key initiative of the organization and be able to provide analytical solutions that provides actionable recommendations to drive the success of the key initiatives
- Lead the development of analytical models for new and ongoing product lines
- On-going monitoring of product lines including but not limited to the success metrics for each model and dashboards required for executive decision-making
- Develop analytical insights for the customer’s healthcare information
- Assist in the accurate and timely preparation of management tools for analyzing clinical, and operational results using enterprise tools
- Serve as an additional point of contact and resource for analytics
- Prepare on-demand analyses and ad-hoc reports and insights
- Research and keep current knowledge of competitive methods in the competitive space
- Capable of applying the latest technologies and methodologies in machine learning, data mining, and predictive analytics to correlate disparate datasets and events, and derive value
- Has a proven ability to learn quickly and works well both independently as well as in a team setting
- Communicate analytical findings and recommendations in a clear and concise way to non-technical audiences, both in oral and written presentations
- Work closely with Information Management teams to automate recurring tasks and improve processes to continually increase efficiency
Qualifications
- Bachelor’s degree in business, economics, statistics, mathematics, actuarial science, public health, health informatics, healthcare administration, finance or related field. Master's degree preferred
- 7+ years of experience in healthcare analytics, creating strategic plans, and operationalizing functional teams in direct relation to meeting business needs or realizing goals tied to strategic objectives
- Experience in strategic planning and solutioning preferred. Broad exposure and understanding of statistical, analytical, or data mining techniques and appropriate application of these capabilities in a business performance environment preferred
- Working knowledge of analytical tools, including R, Python, SAS, Tableau, Hadoop, or related tools preferred
- SQL programming
- Understanding of healthcare claims adjudication and claims content preferred
- Experience with report/dashboard development, data/report automation, self-service capabilities, data design and integration, or data quality and governance preferred
- Experience working in the healthcare setting and utilizing healthcare data to generate insights
- Demonstrate good understanding of healthcare data analytics terminology and concept, e.g., ICD, CPT, REV, DRG, etc.
- Must have demonstrated the ability to solve complex problems with minimal direction
- Experienced with languages used to manipulate data and draw insights from large data sets (e.g., Python, R, SQL, etc.)
Primary Location: 4965 Preston Park Blvd, 350, Plano, TX 75093
Job Type: full-time, hybrid
Job Title: Senior Data Scientist
Salary: $120,000+ per year, based on experience
Benefits:
- Health insurance
- Performance bonus
- Paid time off
- 401K
Schedule:
- Monday to Friday, 9-5
- Hybrid work (2 days in the office)
Our Investigative Analysts are dedicated to identifying, investigating, and eliminating healthcare fraud and other types of wasteful spend. This position is responsible for using [medical] pharmaceutical coding knowledge and critical thinking to determine if a pattern of billing is suspect. The company uses a customized web-portal tool to access claims data. The preferred candidate would be located in the Dallas, Texas area; however, this position is a hybrid position, and a qualified candidate can work remotely with periodic travel to the office. Timely deliverables are of paramount importance.
Primary Responsibilities:
- Identifying and investigating healthcare/pharmaceutical fraud, waste, and / or abusive conduct by the medical profession, insured members, or the broker community in coordination with the customer’s carrier or third-party administrator
- Review prescription and or pharmaceutical claims data and conduct analysis to look for patterns of potential fraud, waste and/or abuse
- Utilizing information from prescription/pharmaceutical claims data analysis, plan members, and other sources to conduct confidential investigations, document relevant findings and report any suspect billing that could result in an overpayment through designated channels
- Conduct data analysis to review claim and case history
- Reviews claims history, medical reviews, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State site, etc.
Required qualifications:
- 3- 5 years’ work experience related to healthcare/pharmaceutical fraud investigations and/or healthcare reimbursement.
- Strong critical thinking skills
- Experience with manipulating and analyzing large datasets
- Ability to be concise, independent and provide defensible decisions in writing
- Detail oriented with excellent communication skills (oral presentations and written) and interpersonal skills
- Strong PC knowledge and skills, including all Microsoft Office products
- 3-5 years’ experience with CPT code terminology
Preferred Qualifications:
- Undergraduate degree in the area of criminal justice or related field or medical/clinical training.
- Must have solid ability to accurately document findings in written form.
- 3+ years of experience working in a PBM, group health business or experience in a health care provider’s practice
- An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Pharmacy and/or commercial health insurance)
- Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
- Certified Coding Specialist (AHIMA, AAPC)
- Experience with computer research
- Experience with data analysis as it relates to healthcare/pharmacy claims adjudication
Our Payment Integrity Analysts are dedicated to identifying, investigating, and eliminating healthcare fraud and other types of wasteful spend. This position is responsible for using medical coding knowledge and critical thinking to determine overpayments. The preferred candidate would be in the Dallas, Texas area; however, this position is a hybrid position, and a qualified candidate can work remotely with periodic travel to the office. Timely deliverables are of paramount importance.
Primary Responsibilities:
- Identify, analyze, and interpret trends or patterns in complex data sets
- Leverages available resources and systems (both internal and external) to analyze claim information and take appropriate action for payment resolution
- Performs review of claims resulting from overpayments related to benefits and policies
- Performs financial impacts of identified defective claims
- Communicate and document findings, including trends and recommendations
- Follow the guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
- All other duties assigned by management
Required qualifications:
- High school diploma or equivalent experience in healthcare claims adjudication, system configuration, and auditing
- Experience with manipulating and analyzing large datasets
- Strong understanding of healthcare claims data, pricing, and claims editing concepts, including UB04 and HCFA 1500 claim content
- Strong working knowledge of health insurance concepts, practices, and procedures, including the understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication
- Strong analytical and research abilities to triage issues and perform reconciliations or data analysis
- Working knowledge of Federal and State regulatory rules regarding claims adjudication
- Ability to organize and prioritize work to meet deadlines
- Excellent written and verbal communication skills
- Good judgment, initiative, and problem-solving abilities
- Ability to handle and resolve complex issues independently
- Knowledge of CPT/HCPCS, ICD-10 coding, and medical terminology
- Ability to learn new policies and processes based on written material
- Ability to establish and maintain professional, positive, and effective work relationships
- Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment
- Experience in healthcare claims adjudication, system configuration, and auditing
- Strong critical thinking skills
- Ability to be concise, independent and provide defensible decisions in writing
- Strong PC knowledge and skills, including all Microsoft Office products
Preferred Qualifications:
- Undergraduate degree in the area of criminal justice or related field or medical/clinical training
- 3-5 years’ experience with CPT code terminology
- Must have solid ability to accurately document findings in written form
- 3+ years of experience working in the group health business or in a health care provider’s practice
- An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Pharmacy and/or commercial health insurance)
- Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar
- Certified Coding Specialist (AHIMA, AAPC)
- Experience with computer research
- Experience with data analysis as it relates to healthcare claims adjudication
Our FWA Carrier Coordinators are dedicated to identifying, investigating, and eliminating healthcare fraud and other types of wasteful spend. The company uses a customized web-portal tool to access claims data. The preferred candidate would be located in the Dallas, Texas area; however, this position is a hybrid position, and a qualified candidate can work remotely with periodic travel to the office. This position is responsible for communicating with insurance carriers and collaborating with them to ensure savings for our clients. Timely deliverables are of paramount importance.
Primary Responsibilities:
- Coordinate with insurance carriers to ensure referral suggested plans of actions are being handled appropriately
- Ensure monthly deliverables are clear and understood by the carriers so appropriate action can be taken
- Review referral inventory and track progress
- Identify priority referrals and escalate issues accordingly
- Coordinate appropriate action to remediate wasteful spend with client’s claims administrator
Required Qualifications:
- Bachelor’s degree preferred
- 7+ years of healthcare claims experience
- 3+ years of experience analyzing healthcare claims data for payment integrity issues within the health insurance world
- Proficiency in Microsoft Excel, Microsoft Word, and Microsoft Outlook
- Excellent written and verbal communication skills
- Ability to simplify complex fraud cases
- Ability to work within hours 7AM - 5PM in respective time zone where hire is located
Preferred Qualifications:
- Clinical coding certification (CPT, Diagnosis)
- Working knowledge of medical coding (CPT, Diagnosis, revenue codes)Certifications or designations pertaining to Fraud, Waste and Abuse
Job Type: Full-time
Salary: $80,000.00 - $90,000.00 per year
Experience: Relevant- 3 years (Preferred)
Work Location: Hybrid
This Job Is Ideal for Someone Who Is:
- Dependable -- more reliable than spontaneous
- People-oriented -- enjoys interacting with people and working on group projects
- Adaptable/flexible -- enjoys doing work that requires frequent shifts in direction
- Detail-oriented -- would rather focus on the details of work than the bigger picture
- Achievement-oriented -- enjoys taking on challenges, even if they might fail
- Autonomous/Independent -- enjoys working with little direction
- Innovative -- prefers working in unconventional ways or on tasks that require creativity
- High stress tolerance -- thrives in a high-pressure environment
