Senior Risk Adjustment Analyst- Medicare Encounters; Hybrid

Resp & Qualifications

PURPOSE:

The Senior Medicare Encounters Risk Adjustment Analyst assumes a pro-active approach in ensuring the accuracy and integrity of key risk adjustment performance metrics through coordination of analytical processes, investigation and interpretation of CMS risk score methodology, risk score calculation, enrollment, premiums, medical and pharmacy claims, and provider data. Incumbent is responsible for performing complex analyses and problem resolution including data integrity extraction, report design, report build and solution deployment.

Additional responsibilities include establishing and maintaining business process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company, as well as external entities, providing coordination and support as required.

ESSENTIAL FUNCTIONS:

• Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are being addressed in a timely manner with interface with departments to improve and correct data. Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy and identification of member health conditions. Update, create and maintain business process and technical workflow documents.

• Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDPS processes and key regulatory deadlines for data submission. Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue.

• Assists in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance. Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in accurate reimbursement based on the CMS-HCC (Hierarchical Condition Code) model. Perform data mining of claims and data to identify trends, data issues and members with missing HCCs.

• Support project management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support management in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved.

• Collaborate across business units to coordinate the development of financial dashboards and models to identify and track revenue and ROI trends. Work with team members to understand and monitor the financial impact of risk adjustment programs. Contribute to developing materials and presenting key updates to leadership regarding risk adjustment programs and provider and member engagement initiatives.

SUPERVISORY RESPONSIBILITY:

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

QUALIFICATIONS:

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 5 years experience with data analysis which includes use of statistical methods, experience with programming language

Knowledge,

Skills and Abilities

(KSAs)

• Experience with SAS, SQL, VBA or other programming language and MS Access Database.

• Experience with EDGE & ACA or Medicaid risk score methodology, including risk score calculation and financial risk receivable calculations.

• Excellent analytical and problem-solving abilities.

• High level statistical abilities. The ability to work independently and with those in various departments and areas not directly reporting to the Division.

• Ability to work with and support Senior Management and to disseminate and summarize information into a format that can facilitate high-level decision-making process.

Salary…