Performance Analyst

Roles and Responsibilities

Job Responsibilities / What you do:

• Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
• Data mining and data analysis are required for conducting investigations on provider claims.
• Support and drive the savings target strategy as set by the Global head of MPM
• Review files, gather information, collect evidence to detect fraud and abuse on claims
• Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties
• Participate in onsite Audits, in-house claims audit and Mystery shopping campaigns
• Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention.
• Assess the scope and determine the methodology needed to carry out an efficient investigation.
• Prepare comprehensive investigative reports and analysis
• Collaborate and communicate internally with associated departments ie legal, finance, claims operations as well as external clients and Providers.
• Consult with legal and regulatory authorities for cases that may involve legal action.
• Manage and ensure generation of periodic dashboards
• Participate in specialized projects and assignments related to procurement, as required.
• Maintain provider relationship in coordination with MPM team
• Use judgment, diplomacy and confidentiality with respect to the complete procurement process, ensuring integrity.
• Preserve the reputation of the company, beneficiaries, payers and all other parties involved.

Key Requirement / What you bring:

• Medical Background (MBBS doctor/Nurse/Paramedic)
• Coding Certification like CPC (Certified Professional Coder), CPMA (Certified Professional Medical Auditor), COC (Certified Outpatient Coder), CCS (Certified Coding Specialist)
• Work experience in insurance industry with claim cycle management
• Expertise in Excel, Power BI, data analytics
• Expertise in general industry trends.
• A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations
• Strong interpersonal/relationship skills.
• Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
• A high degree of integrity, dependability, accountability and confidentiality is required for handling information that is considered personal and confidential.
• Ability to analyze data and interpret results.
• Ability to adapt, meet the changing demands of work environment, any delays or other unexpected demands.
• Ability to treat people with respect under all circumstances, instill trust in others besides upholding the values of the organization.
• Ability to collaborate and work with internal and external colleagues to successfully complete the defined tasks and provide superior customer service.

Desired Candidate Profile

• Analytical Skills:

  • Strong ability to analyze large sets of data, identify trends, and interpret performance metrics to make informed decisions.
  • Proficiency in using data analysis and business intelligence tools (e.g., Microsoft Excel, Power BI, Tableau, Google Analytics, SQL).

• Strategic Thinking:

  • Ability to think strategically and align performance goals with the company’s broader objectives and vision.
  • Capability to forecast performance trends and make adjustments to strategies to maintain growth and efficiency.

• Leadership and Team Management:

  • Excellent leadership skills to guide teams toward achieving performance goals. Ability to motivate and inspire employees to perform at their best.
  • Experience in managing cross-functional teams and driving initiatives across departments.

• Project Management:

  • Strong project management skills to oversee performance improvement initiatives, ensuring that they are completed on time and within budget.
  • Ability to prioritize tasks, manage resources, and monitor progress.

• Communication Skills:

  • Strong verbal and written communication skills to present performance data, influence decision-makers, and provide feedback to teams.
  • Ability to effectively communicate with senior management, department heads, and employees to ensure alignment on goals and initiatives.

• Problem-Solving and Decision-Making:

  • Ability to identify and address performance issues quickly and effectively.
  • Capable of making data-driven decisions that balance short-term objectives with long-term organizational goals.

• Attention to Detail:

  • Careful attention to detail when evaluating performance data to ensure accuracy and precision in reporting.
  • Ability to spot small discrepancies or trends that may indicate larger performance issues.

• Time Management:

  • Excellent time management skills to handle multiple performance-related tasks and initiatives simultaneously, ensuring that deadlines are met.

• Change Management:

  • Ability to lead and manage change within the organization, ensuring that performance improvements are sustainable and well-received by staff.