Health Care Data Analyst - Grievance and Appeals (36392)

The Health Care Data Analyst – Grievance and Appeals sits within the Analytics function, where organizational intelligence, data analysis, and insights drive evidence-based decision making. This position is responsible for the design and development of reports, queries and data extracts using cutting edge quantitative. This Analyst works with Analytics teammates as well as colleagues across all departments in the organization to assist in the evaluation of medical management programs, reporting and analysis of health care costs and utilization, and the development of program assessment metrics, outcomes research and reporting of provider services.

The Analyst is the primary business partner providing operational reports, and supports the Grievance and Appeals Unit (GAU) during official CMS audits. Tracks and trends results at established grievance and appeals standards including correct categorization, timeliness and processing. Conducts ongoing analysis of complaints, grievances, and appeals; identifies trends, participates in reporting

The incumbent Analyst should bring intellectual curiosity, eagerness to learn and develop new skills, creativity, a strong work ethic, and innate ability to collaborate and communicate as part of a team. Background experience in GAU programming MS SQL), public health research, managed care, and / or financial analysis lend themselves well to this role. In this position, passion and skills come together to better serve our members and community.

Duties and Responsibilities :

Responsibilities include, but are not limited to the following :

• Performs data analysis and report writing in support of ad-hoc and recurring requests from all departments using claims, membership, provider network, pharmacy, HEDIS and case management data
• Performs trend analysis, assist in the development and monitoring of key performance indicators and metrics of utilization and cost data to identify patterns over time
• Performs data exploration, solve data problems, and execute algorithmic data processing using data warehouse analytical tools
• Imports, cleans, transforms, and validates health care data with the purpose of understanding or making inferences for business decisions or management purposes
• Analyzes and evaluates medical claims as well as financial and case management data to support medical management initiatives as well as program evaluation projects and other small- and large-scale research and data mining
• Collaborates with Analytic team members to summarize and present data and results of data analysis in charts, graphs, or tabular form
• Assists the Analytics team in the development and production of complex analytic products and other special projects
• Ensures accuracy of reports and data analysis by reviewing and resolving discrepancies encountered in the data
• Develops and maintains GAU reporting for all internal, State and CMS reporting (NCQA, PGP, DOH, DHS, EOHHS,CSM)
• Supports and participates in interaction with Internal Audit and State or Federal regulators
• Develops and maintains reports for NCQA and DHS audits, and participates in the compiling of all grievance, appeals and complaint records for on-site audits
• Provides analysis documentation, assist in developing clear interpretation of results and summary of findings
• Coordinates information from multiple data sources, assure timely delivery of reports and analysis requests, perform quality assurance data review, helps senior management interpret data and contributes to continuous process and product improvement
• Participates in other special project teams as required
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and / or unethical conduct by fellow co-workers, professional affiliates and / or agents