Senior Medical Cost Analytics Advisor

Stellenbeschreibung:

Provide strategy and analytical support for the Payment Integrity team.
Evaluate pre-payment and post-payment editing, clinical coding audits, and recovery programs.
Translate payment integrity program performance and results into actionable insights and business cases.
Identify and size new savings opportunities.
Identify trends, risks, and affordability opportunities across cost containment and payment integrity programs.
Translate complex findings into executive-ready insights and support the strategic roadmap.
Own financial impact assessments and business cases, including forecasts, variance analysis, and performance recommendations.
Support program measurement and performance monitoring through dashboards, scorecards, and executive materials.
Assess billing patterns, coding and reimbursement dynamics, and drivers of wasteful or abusive practices.
Partner across finance, operations, clinical, network, claims, product, vendor, contracting, coverage policy, compliance, reserving, and analytics teams.
Support vendor evaluation and sourcing through analysis of negotiations, pricing structures, and performance guarantees.
Improve data quality, strengthen controls, and enable scalable self-service analytics through automation and AI-enabled tools.

Requirements

Bachelor’s degree in a quantitative field such as Economics, Finance, Data Science, Data Analytics, Actuarial Science, Business, Public Health, or Applied Mathematics, or equivalent experience.
8+ years of progressive experience in medical cost analytics, payment integrity, financial modeling, or related fields.
Strong analytical and technical skills.
Hands-on experience with SQL, Excel, SAS, Tableau, Databricks, or similar platforms.
Knowledge of reimbursement methodologies and coding, including MS-DRG, APCs, HCPCs, and RBRVS.
Familiarity with professional and facility claim constructs.
Experience working in regulated and compliance-aware environments.
Experience modernizing analytics through automation and AI-enabled or advanced analytics methods, such as predictive modeling, NLP, and machine learning.
Ability to translate complex analyses into actionable business insights for senior and executive audiences.
Strong collaboration and influence skills in a matrixed environment.
Self-starter orientation toward continuous improvement, ownership, and impact.
For occasional or permanent home working, cable broadband or fiber optic internet with at least 10 Mbps download and 5 Mbps upload is required.

Core Competencies

Demonstrates expertise in payment integrity and medical cost analytics, with a strong focus on financial modeling, data analysis, and the ability to translate complex findings into actionable insights for executive decision-making. Proficient in utilizing advanced analytics methods and tools to enhance program performance and drive cost containment strategies.