As the Senior Modeling Consultant you will provide healthcare, big data, programming, and fraud expertise to the nation’s largest Medicare fraud detection and prevention system. In this role, you will support the team that liaises between the FPS2 fraud modelers and the system/data team to ensure models are properly integrated into the system, and are monitored to ensure that they are running as intended. Overall, you will help drive development of predictive models to prioritize evaluation of possible fraudulent Medicare providers and claims.
Support CMS and modeling contractors in definition, development, and testing of models and edits in various environments
Assist with identifying and documenting data sources used for each release and model
Work with modelers and other stakeholders to troubleshoot models and edits for optimization of fraud detection
Support activities to query historic claims to determine data sets for testing of models and edits
Conduct complex database queries and claims analyses
Conduct quality reviews of data
Assist with analyzing Model Intake Forms for each release and documenting requested changes per release
Assist with updating/editing the Modeling Guide, Best Practices Documentation, and standard operating procedures
Assist with documenting new data requests outside of model release development
Assist with analyzing and reviewing models with issues that prevent the model life cycle from moving forward
Assist with analyzing and reviewing model streams and populating the model best practices scorecard.
Attend team calls as necessary.
Support operational activities associated with the model and edit lifecycle
Required Technical and Professional Expertise
Bachelor of Science (BS) and 15 years of related experience, OR Masters of Science (MS) and 10 years of related experience, OR Doctor of Philosophy (PhD) and 7 years of related experience.
Experience with healthcare programs including Medicare Parts A, B and DME
Experience and comfort working with, programming, manipulating, and querying large data sets (with an emphasis of Medicare and/or Medicaid claims data)
Experience with DB2
Expertise in one or more of the following areas:
Experience with fraud detection techniques.
Working knowledge of Medicare claims coding and processing systems, healthcare enrollment/eligibility data, healthcare claims data including CPT, ICD-9, and ICD-10.
Experience working with customers to understand data and decision needs.
Familiarity with one or more data analysis tools, data mining tools, and/or statistical packages; specifically SAS and SPSS.
Preferred Tech and Prof Experience
IBM is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. IBM is also committed to compliance with all fair employment practices regarding citizenship and immigration status.