Reporting to the Senior Business Process Engineer, the Clinical Program Analyst plays a key role in the implementation of new medical management systems, the evaluation of medical management (i.e. utilization management and care management) activities and business processes. The Clinical Program Analyst performs data analyses for quality and long term services and supports (LTSS) activities. The Analyst performs data management activities and ensures data integrity and quality in the business systems as well as various reporting databases within the Office of Clinical Affairs (OCA).
KEY FUNCTIONS/RESPONSIBILITIES:
- Consult with subject matter experts to identify information needs and outline optimal reporting formats to achieve business objectives.
- Formulate and implement validation strategies and methods to ensure accurate and reliable data.
- Create and maintain documentation, such as identified issues, summary of data, analysis, written interpretation of results, and related recommendations.
- Create and maintain a catalog of operational reports as related to NCQA, state, federal or other regulatory bodies, including specifications, frequency and submission guidelines. Monitor requirements for changes and revise reports as needed.
- Collaborate with quality and LTSS leadership to develop ongoing program related reporting and data analyses.
- Identify key milestones and delivery dates, gather stakeholders and work groups, and coordinate submissions of internal data to support timely, successful program reporting and data analysis.
- Assist with integration of Medical Policy, UM, Pharmacy, and Vendor programs through the technical and data management of BMCHP and Well Sense forward facing provider code review tools.
- Design and build time study reports that assist UM management in resource allocation and that captures key performance indicators and areas of strategic enhancement. Identifies trends and opportunities for improvement.
- Develop, build and manage the day to day reporting needs for the prior authorization and inpatient utilization teams within UM. Ensure that data and reports are accurate and reflect current business portfolio of products.
- Coordinate major work deemed of critical importance (e.g. regulatory requests, cost savings initiatives) utilizing project management principles and documentation.
- Facilitate intra-departmental, cross-departmental and cross-organizational project teams.
- Manage high visibility, complex projects.
- Participate in regulatory and compliance audits as needed to provide Office of Clinical Affairs data management and analytic support.
- Develop technical logic for analyses to evaluate the effectiveness of quality, LTSS and medical management activities and programs to include tying results to specific financial or other targets.
- Other duties as assigned.
QUALIFICATIONS:
EDUCATION:
- Bachelor degree in Health Care Management, Public Health, Nursing, Information Technology/Computer Science or other health care field required
EXPERIENCE:
- Minimum of 3 years of experience in a managed care environment required
- 4 years of progressively responsible experience in data modeling, informatics and analysis. Commensurate educational experience in related field will be considered
EXPERIENCE PREFERRED/DESIRABLE:
- 2 or more years of experience in Medicaid Managed Care organization strongly preferred
- Project management experience
- Experience with system integration projects including conversion, transitioning and consolidating business to new application platforms
- 3 or more years of experience as a data programmer in a relational database environment including MS Access, SSRS and Tableau
COMPETENCIES, SKILLS, AND ATTRIBUTES:
- Advanced Microsoft Access and SQL programming skills
- Strong analytical and problem-solving skills including but not limited to interpreting alpha-numeric data and identifying outliers and trends
- Proficiency preparing spreadsheets, graphs and other presentation materials
- Knowledge of health care data sets including ICD-10, CPTs, DRGs
- Ability to plan, organize, and manage projects in order to meet established deadlines
- Understands testing methodologies for functional, systems, integration, performance and UAT
- Proficient in compiling information from multiple sources
- Attention to detail with excellent proof reading and editing skills
- Ability to meet deadlines, multi-task, and problem solve in a fast-paced environment with changing priorities
- General knowledge of medical management systems and utilization management
- Effective communication skills (verbal and written)
- Ability to manage relationships with internal and external contacts
- Ability to work effectively both independently and within a collaborative team
- Proven ability to maintain confidentiality
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required Skills
Required Experience