Business Analytics Senior Manager

Sr. Mgr. Business Analytics

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

The Sr. Mgr. Business Analytics is responsible for developing, maintaining, and automating reports and dashboards that track the performance of medical and payment policies. By delivering data-driven insights to leadership and other stakeholders, this role helps optimize business processes, ensure policy compliance, and identify opportunities for efficiency improvements and cost savings.

Data Analysis & Reporting:

• Extract, validate, and interpret large datasets from healthcare claims, authorizations, and payment systems.
• Conduct exploratory data analysis to identify patterns, trends, and deviations in payment or utilization.
• Evaluate medical and payment policy operations, identifying trends, patterns, and variances related to medical cost drivers and utilization patterns.
• Analyze effectiveness of medical and pre-payment policies, and precertification for delivery of insights on performance to leadership.
• Operational efficiency metrics, such as turnaround times and productivity.
• Policy compliance and adherence to regulatory requirements.

Policy Quality & Compliance:

• Review payment policies and procedures for accuracy, identifying gaps and potential inaccuracies.
• Ensure adherence to medical policies and regulatory requirements, such as federal and state legislation and HIPAA.
• Participate in the design and deployment of algorithms or automated edits to ensure correct payment and prevent over payments.

Business Process & System Improvement:

• Collaborate with stakeholders to gather business requirements for new systems and process improvements.
• Translate complex analytical findings and business needs into clear documentation and actionable strategies.
• Provide training and ongoing support to end-users on new systems, processes, and analytical tools.

Report and Dashboard Development:

• Design, build, and maintain standard and ad-hoc operational reports and interactive dashboards using business intelligence tools (e.g., Power BI, Tableau).

Requirements Gathering:

• Collaborate with stakeholders from clinical operations, finance, and other departments to gather business requirements for new reports and analytical projects.

Data Integration and Quality:

• Extract, integrate, and validate data from multiple sources, including claims, membership, and provider data.
• Conduct root-cause analysis of data irregularities and ensure data accuracy.

Communication of Insights:

• Interpret complex data findings and effectively communicate insights and recommendations to both technical and non-technical audiences through clear visualizations and presentations.

Automation:

• Automate recurring reporting processes and workflows to improve statistical efficiency and free up resources for more complex analysis.

Required Qualifications

• 5-7+ years of experience in a data or business analyst role, preferably within the healthcare or health insurance industry with payment integrity, i.e. medical and payment policies, for executives and decision making
• 2-3 years analyzing claim editing rules for payment accuracy and trends
• Demonstrated proficiency in SQL for querying and manipulating large datasets.
• Experience in developing reports and dashboards using data visualization tools like Microsoft Power BI, Tableau and Quick Base Tools.
• Experience with claims data, eligibility data, and medical and payment policy analytics.
• Knowledge of healthcare industry coding systems, including ICD-10 and CPT.
• Familiarity with data governance concepts and data management best practices.

Preferred:

Medical coding certification, ie, Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or other certifications preferred.

Education

Bachelor's degree in a field such as Finance or Mathematics, or…