Business Analytics Senior Manager

CVS Health is committed to building a world of health around every individual. The Sr. Mgr. Business Analytics is responsible for developing, maintaining, and automating reports and dashboards that track the performance of medical and payment policies, delivering data-driven insights to optimize business processes and ensure policy compliance.

Responsibilities:

• Extract, validate, and interpret large datasets from healthcare claims, authorizations, and payment systems
• Conduct exploratory data analysis to identify patterns, trends, and deviations in payment or utilization
• Evaluate medical and payment policy operations, identifying trends, patterns, and variances related to:
• Medical cost drivers and utilization patterns
• Analyze effectiveness of medical and pre-payment policies, and precertification for delivery of insights on performance to leadership
• Operational efficiency metrics, such as turnaround times and productivity
• Policy compliance and adherence to regulatory requirements
• Review payment policies and procedures for accuracy, identifying gaps and potential inaccuracies
• Ensure adherence to medical policies and regulatory requirements, such as federal and state legislation and HIPAA
• Participate in the design and deployment of algorithms or automated edits to ensure correct payment and prevent overpayments
• Collaborate with stakeholders to gather business requirements for new systems and process improvements
• Translate complex analytical findings and business needs into clear documentation and actionable strategies
• Provide training and ongoing support to end-users on new systems, processes, and analytical tools
• Design, build, and maintain standard and ad-hoc operational reports and interactive dashboards using business intelligence tools (e.g., Power BI, Tableau)
• Collaborate with stakeholders from clinical operations, finance, and other departments to gather business requirements for new reports and analytical projects
• Extract, integrate, and validate data from multiple sources, including claims, membership, and provider data
• Conduct root-cause analysis of data irregularities and ensure data accuracy
• Interpret complex data findings and effectively communicate insights and recommendations to both technical and non-technical audiences through clear visualizations and presentations
• Automate recurring reporting processes and workflows to improve statistical efficiency and free up resources for more complex analysis

Requirements:

• 5-7+ years of experience in a data or business analyst role, preferably within the healthcare or health insurance industry with payment integrity, i.e. medical and payment policies, for executives and decision making
• 2-3 years analyzing claim editing rules for payment accuracy and trends
• Demonstrated proficiency in SQL for querying and manipulating large datasets
• Experience in developing reports and dashboards using data visualization tools like Microsoft Power BI, Tableau and QuickBase Tools
• Experience with claims data, eligibility data, and medical and payment policy analytics
• Knowledge of healthcare industry coding systems, including ICD-10 and CPT
• Familiarity with data governance concepts and data management best practices
• Bachelor's degree in a field such as Finance or Mathematics, or similar field
• Medical coding certification, ie, Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or other certifications preferred