Plan Design Specialist jobs in West Virginia

Plan Design Specialist works closely with clients to design group health, dental and/or life insurance plans to create an overall benefit package. Works alongside underwriters, but is not an underwriter role. Being a Plan Design Specialist monitors and analyzes cost trends. May handle more complex plan design. Additionally, Plan Design Specialist requires a bachelor's degree or its equivalent. Typically reports to a supervisor or manager. The Plan Design Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Plan Design Specialist typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)

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SIU Fraud Analytics Specialist
  • The Health Plan of West Virginia Inc
  • Wheeling, WV FULL_TIME
  • The SIU Fraud Analytics specialist is part of a team focused on the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse, program integrity initiatives, and the recovery of overpayments in a multi-payer environment. This is a data-intensive position. The Specialist is or will become a data mining and analysis expert, responsible for leveraging analytical tools to provide in-depth data analysis in support of fraud investigations, identifying outliers and/or aberrant billing patterns; potential fraud, waste, and abuse (FWA); and vulnerabilities or overpayments; as well as proactively generating leads for further investigation in pursuit of program integrity. The Specialist may occasionally assist other team members in fulfilling data requests and analytics for MFCU, the WVOIC, the ODI, the USAO and other law enforcement or regulatory entities. The Fraud Analytics Specialist will also conduct reviews of payment integrity matters (where fraud is not suspected), completing a thorough and ethical investigation.

    Required:

    • EDUCATION: Associate's degree in any field, with preference for degree in Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field. (Two [2] years of relevant experience as described below in QUALIFICATIONS DESIRED section may be substituted for the required education.)
    • EXPERIENCE: At least 1 year of experience working with Microsoft Excel in a professional environment.
    • Advanced proficiency in Microsoft Excel; basic proficiency in Word, Outlook and other common programs.
    • Strong organizational and analytical skills.
    • Detail oriented, with a high level of accuracy.
    • Effective written and oral communication skills.
    • Ability to plan and execute projects independently and meet tight deadlines.

    Desired:

    • Education: Bachelor's degree in Accounting, Business, Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field; or a Bachelor's degree in any field and a Master's Degree in any fraud-related discipline.
    • At least 2 years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE.
    • Proficiency in fraud analytics.
    • Advanced technical skills related to data mining and analysis of healthcare claims data.
    • Experience with SQL/Microsoft Report Builder and Report Manager.
    • Experience in Medical Terminology and/or Coding.
    • Experience in a federally regulated environment such as Medicaid or Medicare Advantage.

    Responsibilities:

    • Leveraging analytic tools to provide in-depth data analysis in support of fraud investigations and payment integrity activities.
    • Conducting strategic analysis of healthcare claims data from initial data scoping through transformation and validation, and conveying results in verbal, written, and visual formats.
    • Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, and proactively, to identify trends and patterns indicative of FWA.
    • Utilizing fraud detection software and large data sets to identify outliers and inform decision-making related to FWA investigations and the identification and recovery of overpayments.
    • Obtaining, cleaning, normalizing, and validating healthcare claims data for the purposes of supporting FWA investigations and informing investigative and recovery decisions.
    • Drafting clear and concise, yet appropriately detailed reports of findings which may include recommendations related to case disposition, corrective actions, and/or process improvements.
    • Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads.
    • Responding to requests for information from various sources, including Medicaid, I-MEDIC, MFCU, and the WV OIC.
    • Expertise in the use of fraud detection software and case tracking system.
    • Creating and delivering training on databases, analytics software, and other relevant systems and techniques.
    • Identifying and recommending process improvements to reduce FWA.
    • Tracking, trending, and reporting identified metrics, including dashboard reporting.
    • Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations.
    • Investigating matters of payment integrity as assigned by the FWA Data Analytics Manager.

  • 7 Days Ago

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CMT Laboratory Manager and Concrete Mix Design Specialist
  • The Thrasher Group, Inc.
  • Scott, WV FULL_TIME
  • Discover Your Potential at The Thrasher Group At The Thrasher Group, we're dedicated to enriching the communities where we live and work, particularly in Charleston, WV, where our efforts are deeply r...
  • 7 Days Ago

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Dental Director - West Virginia
  • LIBERTY Dental Plan
  • UNKNOWN, WV FULL_TIME
  • Building Brighter Futures, One Smile at a Time We are building a new team in West Virginia and are looking for a new Dental Director to lead our team! Position Overview: As the Dental Director for the...
  • 3 Days Ago

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Retirement Plan Administrator
  • Strongpoint Partners
  • Falls, WV FULL_TIME
  • Retirement Planners & Administrators (RPA), a Strongpoint Partner, is seeking a highly motivated and ambitious Retirement Plan Administrator who will provide full client services to a designated casel...
  • 22 Days Ago

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Senior Retirement Plan Administrator
  • Strongpoint Partners
  • Falls, WV FULL_TIME
  • Retirement Planners & Administrators (RPA), a Strongpoint Partner, is seeking a highly motivated and ambitious Senior Retirement Plan Administrator who will provide full client services to a designate...
  • 1 Month Ago

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Credentialing Rep
  • The Health Plan of West Virginia Inc
  • Wheeling, WV FULL_TIME
  • Under the direct supervision of the Manager of Credentialing, responsible for credentialing of providers and associated activities in support of the credentialing process in accordance with establishe...
  • 20 Days Ago

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Graphic Design Specialist
  • Acl Digital
  • San Diego, CA
  • Job Title: Graphics Software Engineer Location: San Diego, CA (Onsite) Duration: Contract Project Job Description: Top 5...
  • 3/29/2024 12:00:00 AM

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Design Specialist
  • Fine Fettle
  • Hartford, CT
  • About the Role: Fine Fettle is seeking a Brand & Design Lead to spearhead our brand strategy and directly contribute to ...
  • 3/28/2024 12:00:00 AM

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Design Specialist
  • Synerfac Technical Staffing - Cherry Hill
  • Springfield, NJ
  • Job Description Job Description Our client is looking for an Design Specialist to join their North Jersey team. They are...
  • 3/28/2024 12:00:00 AM

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Graphic Design Specialist
  • Dexian
  • Getzville, NY
  • Job Title: Graphics Presentation Specialist Location: Getzville, NY Duration: 12 months Pay Range: $30/hr to $33/hr Job ...
  • 3/28/2024 12:00:00 AM

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CAD Design Specialist
  • OBEC Consulting Engineers
  • Anchorage, AK
  • For over 60 years, DOWL has thrived as an established, highly reputable, civil engineering firm, recognizing that the fo...
  • 3/28/2024 12:00:00 AM

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Design Specialist
  • Akkodis
  • Sterling Heights, MI
  • Akkodis is searching for a highly skilled Senior Designer to join our team in Metro Detroit. In this role, you will play...
  • 3/27/2024 12:00:00 AM

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Design Specialist
  • Akkodis
  • Phoenix, AZ
  • Akkodis is seeking a candidate for a Sr Design Specialist position with one of our Fortune 500 partners in the Aerospace...
  • 3/27/2024 12:00:00 AM

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Design Specialist
  • SERVPRO of East Mahoning County
  • Warren, OH
  • Job Description Job Description Benefits: 401(k) 401(k) matching Competitive salary Dental insurance Health insurance Pa...
  • 3/25/2024 12:00:00 AM

West Virginia (/vərˈdʒɪniə/ (listen)) is a state located in the Appalachian region in the Southern United States and is also considered to be a part of the Middle Atlantic States. It is bordered by Pennsylvania to the north, Maryland to the east and northeast, Virginia to the southeast, Kentucky to the southwest, and Ohio to the northwest. West Virginia is the 41st largest state by area, and is ranked 38th in population. The capital and largest city is Charleston. West Virginia became a state following the Wheeling Conventions of 1861, after the American Civil War had begun. Delegates from so...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Plan Design Specialist jobs
$66,525 to $90,168

Plan Design Specialist in Birmingham, AL
SmithGroup creates exceptional design solutions for healthcare, science and technology organizations, higher education and cultural institutions, urban environments, diverse workplaces, mixed-use and waterfront developments, and parks and open spaces.
December 13, 2019