Job Description
Serves as a strategic analytics partner to the Special Investigations Unit (SIU) and Payment Integrity teams by delivering actionable business intelligence, financial reporting, operational insights, and statistically sound audit support. This role combines advanced data analysis, dashboard development, healthcare claims expertise, and stakeholder engagement to identify fraud, waste, abuse, payment accuracy opportunities, and operational improvement initiatives.
The analyst develops reporting and analytical solutions that support provider investigations, overpayment recovery efforts, prepayment and post-payment audit programs, and executive decision-making. This role is responsible for translating complex healthcare data into meaningful insights, measuring program effectiveness, supporting statistically valid sampling methodologies, and driving measurable savings and operational efficiencies across the organization.
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.
What You Bring
Required
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.
Preferred
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
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
$89,174.00 - $142,679.00
Skills
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC . If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com .
About Us
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We're committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.
Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.
Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.
Authorization to Work in the United States
We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.
Request Accommodations
Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at HR.Staffing@bcbsnc.com .
Blue Cross NC is a Hybrid Flex company. Whether the role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any of our approved states:
Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming
