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International Business Machines Corp. (IBM Corporation)

Watson Health - Senior Managed Care Analyst - Truven

International Business Machines Corp. (IBM Corporation) - Indianapolis, IN

Job Description

Position Summary

The Senior Managed Care Analyst is a new position to support the Indiana FADS contract. The Analyst will be responsible for building and defining PI's relationship with the Managed Care Organization’s (MCO's) Special Investigation Units (SIUs). This relationship needs to be focused on assuring compliance with the SIU related areas of Indiana's contracts with each of the MCOs.

Essential Responsibilities

At first, the PI Managed Care Analyst will work with the State’s PI Director, but will then eventually perform the following activities independently: Establish and facilitate routine individual meetings with each MCO SIU, and group meetings with all MCOs' SIU staff to review and discuss investigations in process.

Continually review, monitor, provide feedback, and take steps to resolve deficiencies in MCO compliance to all PI and SIU-related contract requirements.

Effectively monitor MCO benefit compliance.

Assure that MCO referrals are reviewed and validated, and that appropriate resulting actions are taken. This may include making recommendations to the other MCOs and/or the PI group (to review provider's performance in the Medicaid fee-for-service program) to also review and investigate the same provider. When the MCO identifies a credible allegation of fraud, this would also involve assuring that the MCOs report the provider to the Medicaid Fraud Control Unit (MFCU) and, as directed, to suspend payment to the provider.

Assure that the MCO is meeting staffing requirements and if not has timeframes for doing so.

Assist in development and implementation of departmental policies and procedures as related to MCO performance.

Monitor and ensure Federal CMS requirements are being met and work with the MCO to develop a corrective action plan to address any unmet areas.

Maintain a current knowledge of Federal and State legislation, legislative initiatives, and regulations that impact the MCOs' PI-related and SIU functions.

Perform other duties as assigned.

Work closely with the client and project team to develop and implement an annual analytic work plan.

Formally create, enhance and document policies and procedures as they relate to algorithm creation and completion.

Consistently examine progress against plan and prioritize schedules, ensuring analytic deliverables are completed timely and annual fiscal goals are met or exceeded.

Oversee the design, application, interpretation, documentation, and presentation of all comprehensive fraud, waste and abuse algorithms.

Design, execute and present complex analysis as a member of the analytic team.

Provide feedback and detailed review for all deliverables (algorithm programming, algorithm write-ups, letters, etc.) to guarantee deliverables are reliable and completed accurately.

Work in partnership with the Indiana Medicaid Fraud Control Unit; generate all necessary reports needed relative to MCO PI operations

Job Requirements:


REQUIRED Skills and Experience

4 years work experience in a managed health care system.

Must be knowledgeable of managed care claims payment processes.

Knowledge of federal and state public health care programs.

Must be highly self-motivated, possess initiative and be able to work independently.

Working knowledge of reporting systems and ability to accurately interpret complex statistical data and reports.

Ability to critically assess effectiveness of programs

Ability to develop and present recommendations in areas of policy and procedure.

3 years managing/supervising staff.

Experience in data evaluation, database development.

Prior experience with health care claims, provider relations, program integrity, fraud and abuse.

Experience managing in a fast-paced, goal oriented environment.

Experience developing policies, procedures, processes and workflows.

Willingness to spend time working onsite with the client and travel occasionally.

Additional Information


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Watson Health - Senior Managed Care Analyst - Truven International Business Machines Corp. (IBM Corporation) - Indianapolis, IN, United States


Location: Indianapolis, IN

Company Profile:
International Business Machines Corporation provides information technology (IT) products and services worldwide. The company’s Global Technology Services segment provides IT infrastructure and business process services, including outsourcing, process, integrated technology, cloud, and technology support. Its Global Business Services segment offers consulting solutions for strategy and transformation, application innovation, enterprise applications, and smarter analytics; and application management, maintenance, and support services. International Business Machines Corporation’s Software segment offers middleware and operating systems software, such as WebSphere software to integrate and manage business processes; and information management software for database and enterprise content management, information integration, data governance, data warehousing and analytics, business analytics and intelligence, and predictive analytics. This segment also provides Tivoli software for cloud and datacenter management, enterprise endpoint and mobile device management, asset and facilities management, storage management, and security systems; Rational software that supports software development; and Mobile Software for platform and application development, mobile security, and mobile device management. The company’s Systems and Technology segment provides computing power and storage solutions; and semiconductor technology, products, and packaging solutions. Its Global Financing segment provides lease and loan financing to end users; commercial financing to dealers and remarketers of IT products; and remanufacturing and remarketing services for equipment. The company was formerly known as Computing-Tabulating-Recording Co. and changed its name to International Business Machines Corporation in 1924. International Business Machines Corporation was founded in 1910 and is headquartered in Armonk, New York.