Resp & Qualifications
PURPOSE:
The Senior 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 and HHS risk score methodology, risk score calculation, ACA enrollment, premiums, medical and pharmacy claims, EDGE analysis and provider data. Incumbent is responsible for performing complex analyses and problem resolution including data 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.
We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS:
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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 maximizing 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.
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Propose innovative approaches to create or improve automation and optimize data and analytic processes as well as reporting. Provide programming support to extract and analyze data from different enterprise systems. Develop, implement and maintain a provider and medical record collection database. Lead cross-functional and operational teams toward the goal of improved risk adjustment scores.
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Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDGE 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.
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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.
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Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are being addressed in a timely manner. Interface with departments to improve and correct data
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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.
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Conduct analyses to develop a comprehensive understanding of a provider?s risk score trends, EMR systems and contracting arrangements to recommend and generate provider-specific engagement plans. Oversee the analysis and interpretation of provider-specific results and risk score trend information. 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.
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)
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Experience with SAS, SQL, VBA or other programming language and MS Access Database.
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Experience with CMS risk score methodology, including risk score calculation and financial risk receivable calculations.
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Excellent analytical and problem-solving abilities.
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High level statistical abilities.
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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.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $64,080 - $127,270
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
ACA Risk Adjustment
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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