Sr BI Analyst

📋 Description

• • Blue Cross and Blue Shield of North Carolina is seeking a highly skilled and experienced Senior Business Intelligence (BI) Analyst to join their dynamic Medical Economics team. This pivotal role is centered around Payment Integrity analytics, a critical function for identifying and mitigating financial losses within the healthcare system. You will be instrumental in developing sophisticated analyses designed to detect cost leakage, inappropriate utilization patterns, coding anomalies, and various payment errors across both medical and pharmacy claims.
• • This position offers a unique opportunity to leverage your robust technical BI expertise, combined with a deep understanding of healthcare claims data and the ability to translate complex analytical findings into clear, actionable insights. You will be a key partner to clinical, operations, and executive stakeholders, guiding them with data-driven recommendations to improve financial performance and operational efficiency.
• • As a Senior BI Analyst, you will lead comprehensive analytical support for Payment Integrity (PI) programs. This includes conducting in-depth pre-pay and post-pay claims reviews to identify potential issues before or after payment. You will perform detailed coding intensity and DRG (Diagnosis-Related Group) shift analyses to understand changes in coding practices and their financial impact. Furthermore, you will analyze E&M (Evaluation and Management) level distributions and complexity migrations to ensure accurate and appropriate billing.
• • A significant aspect of your role will involve quantifying the financial opportunities associated with PI findings. This includes calculating potential savings on a per-member-per-month (PMPM) basis and estimating total financial impact. You will also be responsible for tracking the realized savings from implemented interventions, demonstrating the value of the PI program.
• • You will collaborate closely with various internal teams, including PI operations, Special Investigations Unit (SIU), Revenue Cycle Management (RCM), and external vendor teams. This partnership is crucial for prioritizing interventions based on their economic value and operational feasibility, ensuring that resources are allocated effectively.
• • In terms of Data Analysis & BI Development, you will be responsible for developing and maintaining sophisticated dashboards, reports, and analytical models. These tools will utilize a wide range of data sources, including medical and pharmacy claims, member eligibility, provider information, and industry benchmarks.
• • You will perform rigorous trend analysis, benchmarking against industry standards, and peer comparisons to identify outliers and emerging risk areas within the claims data. This proactive approach helps in anticipating and addressing potential issues before they escalate.
• • A key deliverable will be the design of repeatable and scalable analytical frameworks. These frameworks will support the ongoing monitoring of PI program performance, ensuring consistent and reliable insights over time.
• • Your role will also encompass significant Stakeholder Engagement & Storytelling. You will be adept at translating complex analytical findings into clear, concise, and compelling narratives tailored for diverse audiences, including leadership within Medical Economics, Finance, Network Management, and Clinical departments.
• • You will provide critical support for executive-level presentations, crafting well-structured insights, impactful visuals, and actionable recommendations. Your ability to communicate complex data in an understandable manner will be essential for driving decision-making at the highest levels.
• • You will serve as a trusted thought partner to PI leadership, contributing to the shaping of strategy, the development of key performance indicators (KPIs), and the overall roadmap for the Payment Integrity function.
• • Data Governance & Quality are paramount. You will ensure that all analytical outputs are accurate, reproducible, and strictly aligned with enterprise data definitions and standards. This commitment to quality ensures the reliability and trustworthiness of the insights provided.
• • You will collaborate with data engineering and enterprise analytics teams to enhance data availability, improve data reliability, and optimize data performance, ensuring you have the best possible foundation for your analyses.
• • This role requires a proactive, analytical mindset with a strong ability to work independently and as part of a team, driving initiatives from conception to completion within a complex healthcare environment.