Note: The job is a remote job and is open to candidates in USA. Blue Cross NC, operating through NC Health Affiliates LLC, provides health insurance and healthcare services. The BI Analyst serves as a strategic analytics partner to Special Investigations Unit and Payment Integrity teams by developing business intelligence, financial reporting, dashboards, and statistically sound audit support. The role analyzes healthcare data to identify fraud, waste, abuse, payment accuracy opportunities, and operational improvements.
Responsibilities
- Partner with Special Investigations Unit (SIU), Payment Integrity, Clinical, Finance, and operational stakeholders to identify business needs and develop analytical solutions that support fraud, waste, abuse detection, payment accuracy, and operational performance management
- Design, develop, and maintain dashboards, scorecards, reports, and self-service analytics solutions that provide actionable insights into investigation outcomes, provider risk, savings, recoveries, cost avoidance, inventory management, and key performance indicators
- Analyze healthcare claims, provider, member, audit, and investigation data to identify trends, anomalies, emerging risks, and opportunities for financial and operational improvement
- Develop recurring and ad hoc financial and operational reporting used by leadership to measure program effectiveness, resource utilization, productivity, return on investment, and strategic objectives
- Design, execute, validate, and document statistically valid random sampling methodologies to support provider audits, overpayment identification, error rate measurement, and extrapolation activities
- Collaborate with business partners, BI Analysts, Data Scientists, and others to define data requirements, improve data quality, and operationalize advanced analytical solutions
- Facilitate requirements gathering, solution design, and stakeholder review sessions to ensure reporting and analytical solutions meet business objectives and deliver measurable value
- Validate data accuracy, reconcile reporting outputs, and ensure consistency of financial, operational, and analytical metrics across multiple systems and audiences
- Communicate analytical findings, insights, risks, and recommendations to business partners and leadership through effective visualizations, presentations, and written summaries
- Establish and maintain reporting standards, documentation, governance practices, and development methodologies to ensure scalable, reliable, and sustainable analytical solutions
- Manage multiple projects and priorities simultaneously while proactively communicating status, risks, dependencies, and opportunities to stakeholders and leadership
Skills
- Bachelor's degree or advanced degree (where required)
- 3+ years of experience in healthcare analytics, SIU, Payment Integrity, or a related field
- In lieu of degree, 5+ years of experience in related field
- Strong analytical, problem-solving, and communication skills
- Experience supporting Special Investigations Unit (SIU), Fraud, Waste & Abuse (FWA), Payment Integrity, claims auditing, or provider payment review functions
- Knowledge of healthcare claims processing, reimbursement methodologies, CPT, HCPCS, ICD-10, DRG, and provider billing practices
- Experience with statistical sampling methodologies, confidence intervals, extrapolation, and audit-related analytics
- Experience measuring healthcare savings, recoveries, cost avoidance, and operational performance metrics
- Experience with Snowflake
- Experience building AI agents
Benefits
- Annual Incentive Bonus, based on annual corporate goal achievement and individual performance
- 401(k) with employer match
- Paid Time Off (PTO)
- Competitive health benefits and wellness programs
Company Overview
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