Claims Trending and Analysis

Job Summary

Consultants are seasoned, subject matter experts who apply specialized knowledge, typically as an individual contributor or through coordination of a team of experts. Incumbents use their discipline-specific and/or institutional knowledge to perform and coordinate department activities.  This role is accountable for analyzing large amounts of date to identify high risk claim billing/payment trends and collaborate with stakeholders to develop and implement targeted interventions to mitigate emerging risks that have organization-wide impacts.  In addition, this role will have frequent contact with internal and external business partners and is accountable to communicating findings, updates, and recommendations to stakeholders across the organization, including Executive Leadership. This role will also assess and influence process improvements to optimize the use of analytical and AI-powered tools, leveraging their capabilities to drive business efficiency and effectiveness.

Essential Functions

The essential functions listed represent the major duties of this role, additional duties may be assigned.

• Analyzes data from AI tools and synthesizes collected data/information and advises clients on risks, claims control options, cost benefits and impacts on client’s business processes, systems, employees, etc.
• Oversees reporting, monitoring and evaluation of activities related to identified claims billing and payment trends.
• Provides consultative support to organization management within context of overall strategic objectives and broad policy; typically supports senior management. Focus will be recommendations on claim payment controls based on assessment of claims trending data provided by AI tools. 
• Has frequent contact with internal and external business partners to obtain and share information for influencing decisions, recommending FWA concepts, and/or providing advice and counsel that impacts business objectives.
• Acts as communications lead for department.  Will develop communication messaging and presentations for the organization.  Acts as coordinator for AI tools used to mitigate medical cost.
• Supports development and implementation of new IT and business capabilities and business processes as the Product Owner for these AI tools.

Qualifications

Required Work Experience

• 6+ years related work experience. Experience Details: 
• Related Bachelor’s degree or additional related equivalent work experience 
• General understanding of claims processing
• Experience coordinating cross functional teams
• Experience setting and managing multiple priorities
• Ability to adapt in a fast-paced environment 
• In-depth understanding of health care business operations and management
• Well-developed problem-solving skills and solutions development

Preferred

• Project Management Professional certification
• Claims auditing experience
• Familiarity with Claims processing systems (Diamond, Quest, Content Central, etc.)

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. 

What We Offer: 

As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. 

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: 

• Medical, dental, vision, life and global travel health insurance;

• Income protection benefits: life insurance, short- and long-term disability programs;

• Leave programs to support personal circumstances;

• Retirement Savings Plan including employer match;

• Paid time off, volunteer time off, 10 holidays and 2 well-being days;

• Additional voluntary benefits available; and

• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. 

Annualized Salary Range: $92,100 - $149,600

Typical Annualized Hiring Range: $92,100 - $115,100

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.