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 initiatives 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
• Serve as an additional point of contact and on-demand resource for analytic requests
• 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
• Experienced with languages used to manipulate data and draw insights from large data sets (e.g., Python, R, SQL, etc.)
• Working knowledge of analytical tools, including machine learning, statistics, SAS, Tableau, Hadoop or related tools preferred
• 3+ 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
• Understanding of healthcare claims adjudication and claims content preferred
• Demonstrate good understanding of healthcare data analytics terminology and concept, e.g., ICD, CPT, REV, DRG, etc.
• 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
• Experience with report/dashboard development, data/report automation, self-service capabilities, data design and integration or data quality and governance preferred
• Must have demonstrated the ability to solve complex problems with minimal direction

Job Type: Contract

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Compensation package:

• Bonus opportunities

Experience level:

• 3 years

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Education:

• Bachelor’s (Required)

Experience:

• Machine learning: 3 years (Required)
• SQL: 3 years (Required)
• Healthcare claims: 3 years (Required)
• Python, R, or equivalent: 3 years (Required)

Work Location: Remote

Job Summary:

SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight detects, corrects and prevents healthcare fraud, waste, abuse and erroneous payments by partnering with self-funded employer groups. Our process utilizes proprietary AI-informed and machine-learning data analytics to work with carriers and TPAs directly, requiring minimal employer involvement to save significantly and reduce plan spend without interrupting employee benefits or requiring employee behavior changes. 

Our investigative and clinical analysts are dedicated to identifying, investigating and eliminating inappropriate health claim payments for our clients. This position is responsible for using medical coding and pharmaceutical industry knowledge along with critical thinking to identify suspect pharmacy claims and generate detailed documentation in support of our mission. The preferred candidate is located in the Dallas, Texas area and is available to work a hybrid schedule with one day per week in the office; however, fully remote working arrangements will be considered for the right candidate.  

Primary Responsibilities 

Data analysis and Review: 

• Utilize data mining techniques and software to review prescription claims data 
• Identifying patterns and irregularities that are indicators of aberrant billing and claim payments 
• Conduct comprehensive data analysis to examine pharmacy and medical claims history 
• Conduct investigative research using online resources such as the State Pharmacy licensing boards, state and federal exclusions list and other online resources 

Reporting and Communication:  

• Communicate findings and analysis results to relevant stakeholders, including management, internal and external business partners, ensuring all parties are informed of potential payment errors and suspect billing 

Educational Requirements*

Undergraduate Degree 

• Bachelors in a relevant field such as pharmacy, criminal justice, healthcare administration or business  

Advanced Degree (preferred) 

• Masters in a relevant field such as pharmacy, healthcare administration, business administration, public health or other related field 

 * Significant relevant experience may be considered in lieu of the degree requirement.  

Professional Experience 

Relevant Experience 

• Minimum of 2-3 years of pharmacy experience in operations, fraud detection, data analysis, compliance or related field 

Analytical Experience 

• Proven experience in data mining and using analytical software to detect aberrant billing behavior and inappropriate payments resulting in detailed written reports   

Technical Skills 

• Intermediate skill level with Microsoft Office products, especially Excel for data manipulation and analysis 
• Working knowledge skill level with Database Management and claims processing systems 

Key Competencies 

• Attention to Detail – high level of accuracy and attention to detail in data analysis and report preparation  
• Analytical Skills – strong analytical and problem-solving skills to identify trends and irregularities in data 
• Communication skills – excellent written and verbal communication skills for preparing reports and presenting findings to stakeholders  
• Integrity and Confidentiality – high ethical standards and ability to handle sensitive information confidentially  
• Regulatory Knowledge – understanding of healthcare regulations, pharmacy practices, and compliance requirements related to fraud, waste and abuse  
• Team Collaboration – strong ability to work collaboratively with cross-functional teams including data science, carrier relations and medical teams  

Preferred Certifications  

• Certified Pharmacy Technician (CPhT) 
• Accredited Health Care Fraud Investigator (AHFI)  
• Certified Fraud Examine (CFE)