Senior Data Analyst, Operations

Information Technology Miramar, Florida


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina and offers Medicare Prescription Drug Plans in 42 states plus DC.

Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals.  All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.

Job Summary:

Reporting directly to the Vice President of Pharmacy Operations, as a Senior Data Analyst you will be responsible for the support, maintenance, and development of strategies for the part D (Pharmacy) program and Part C operations unit over enrollment, billing, claims, appeals and grievances and call center through Clear Spring Healthcare’s various Advantage and part D health plans. The analyst will ensure data accuracy & integrity and completeness within the various internal and external data sources used for end-user reporting. Conduct highly complex quality management, procedural documentation, and operations and efficiency analysis on key data sets.

Main Accountabilities:

  • Identify data-related issues, conduct root cause analyses, and facilitate resolution of known issue by working directly with end-users, IT Staff, departmental SME’s and third-party vendors.
  • Work with the Operations and Pharmacy Teams as needed to ensure that pharmacy claims data is analyzed and reported.
  • Assist as needed in the creation and support of the Part D reports for Star Ratings for all lines of business. Including but not limited to Adherence program, Cholesterol in diabetics, and Medication Therapy Management.
  • Creation of utilization management reports that include retrospective drug utilization evaluation to meet CMS standards.
  • Creation of Opioid analytics and output that can be automated to communicate to providers based on members that meet Opioid criteria and support Drug Management Program requirements.
  • Provide reports of high dollar claims and utilization by member, pharmacy, and provider.
  • Work on reports that maximize rebate dollars and overall net spend on Part D medications with additional support to manage outreach to members and providers.
  • Identifies new and maintains existing sources of data to ensure the availability of information for reporting purposes.
  • Review Part D reporting requirements on quarterly basis for quality assurance and ensure data integrity is maintained by delegated vendors and take lead in preparation of reports meeting all deadlines.
  • Claim rejection automated system the checks rejection code against formulary, pharmacy, and member to ensure proper follow up for rejected claims.
  • Build reports that use CMS and MEDIC data for suspected providers, pharmacies, and medications that are used in FWA.
  • Create reports based on per member per month utilization by line of business and review any outliers.
  • Claim review to ensure that medications paid under the appropriate area for part A, B, or D depending on current member status.
  • Advanced working knowledge writing SQL queries, with the ability to lead/participate in data mapping of various sources.
  • Develop, manage, and maintain along with the unit level Vice Presidents, Directors and the COO, the weekly department level key performance indicator scorecards and action item reporting for review and presentation to the CEO for the weekly management meetings.
  • Support operations analysis and ad hoc unit root cause and solutioning analysis to the line managers across all operating areas under the office of the COO.
  • Respond to ad hoc reporting requests as needs arise, and work with all Company departments to identify and meet reporting requirements. Design, test, and execute to meet reporting needs working with business partners. Make recommendations to management/leadership based on business case and analysis.

Qualifications:

  • Master’s degree in healthcare administration or related health/IT field
  • Minimum 3 years of Health data analytics experience required; 5 years preferred
  • Minimum 7+ years of work experience in healthcare and/or Medicare
  • Advanced SQL, PowerBI or Tableau experience
  • Strong written and verbal communication skills with sufficient technical and operational capabilities to communicate with multiple teams at every level of the organization
  • The ability to work independently and prioritize
  • Other duties as assigned