Informatics Research Analyst
Philadelphia, Pa, Us
Fraud department sought improvement in dollar return on Modifier 25 investigations; they wanted specific claims to scrutinize. I constructed and productionized a PySpark random forest model that output likelihood of fraud, waste or abuse for most recent 3 months of claims; investigators in midst of pursuing first batch of claims when I relocated.With a list of illegal Special Enrollment Periods enrollees, I visualized, explored and tested differences between known illegal SEP enrollments and general SEP enrollments. I referred 40 high-cost members for investigation and uncovered manipulation of out-of-state laboratory benefits that resulted in a product revamp and expected savings of $10 million in 4th quarter 2016.Given limited Medicare marketing budget, the marketing team hoped to optimize spending towards members unlikely to re-enroll. I constructed predictive models for each Medicare product that output a member's likelihood to churn. This improved identification of churners from 41% to 63% and attrition dropped from 7% to below 5%.Authorization-based referrals to care management were set to expire; this required a new system to maintain the referral source. I modeled each member's future medical cost to prioritize referrals. The new method included a member's medical history, demographic information, and all authorization types; this referred additional $300 million in medical cost to care management over old referrals.Marketing department dissatisfied with direct-mail targeted by zip code, they hoped to use individual household information. I clustered prospects with K-means, described the story of each cluster's characteristics for the creation of relevant copy. We saw the expected product purchased 10% closer to plan than prior year.