Website CES, LLC
Integrity At Work
Job Description Summary:
The Data Analyst II will perform in-depth evaluation and analysis of potential fraud cases and requests for information using claims information and other sources of data. Support the development of complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis.
Work with local management, investigators, and analysts to provide reactive and proactive case development support and to fulfill law enforcement data requests
Communicate effectively with internal and external customers, including federal law enforcement officers
Validate data analysis results and analytically identify potential fraud, waste and/or abuse situations in violation of Medicare/Medicaid laws, guidelines, policies, and regulations
Support management requests for CMS reporting requirements
Utilize data analysis techniques to detect aberrancies in Medicare/Medicaid claims data and proactively seeks out and develops leads and cases received from a variety of sources including CMS and OIG, fraud alerts, and referrals from government and private sources
Prepare, develop and participate in provider, beneficiary, law enforcement, or staff training as related to Medicare fraud, waste and/or abuse data analysis
Maintain chain of custody on all documents and follow all confidentiality and security guidelines
Comply with and maintains various documentation and other reporting requirements as needed
Bachelor’s degree in statistics or related discipline and/or relevant work experience as a data analyst.
2 years’ experience in data analysis as well as demonstrated knowledge of health care and claims or a combination of education and equivalent work experience
Must have and maintain a valid driver’s license issued by his/her state of residence
High proficiency level with MS Access and MS Excel
Working knowledge of SAS and/or other applications to perform various types of data analysis
Knowledge of Medicare and Medicaid rules and regulations
Demonstrated knowledge of various database management systems in order to input, extract or manipulate information.
Demonstrated experience and knowledge of health care information (health claims data; specifically, Medicare and Medicaid, ICD-9-CM and ICD-10-CM codes, physician specialty codes, pharmaceutical data including NCPDP file formats and codes, provider identifiers, etc.)