Job Location: Manhattan
Supports analytic activities for optimizing risk adjustment revenue through closing gaps in coding and care delivery across VNS Health Medicare. Uses business intelligence, analytic, and data science techniques to improve risk adjustment results, includings obtaining data from various internal sources, understanding relevant differences between each data source, designing and structuring files for analysis, and performing and interpreting descriptive, bivariate, and multivariate analyses. Works under general supervision.
Responsibilities
- Leads the development of Risk Adjustment Program Analytics to address key strategic problems such as the accurate identification of members for gap closure and quality improvement opportunities through data analytics to drive improved performance on risk adjustment optimization initiatives.
- Designs and conducts analytics and research projects that support Risk Adjustment; communicates results to leadership.
- Provides leadership with information to answer the question of whether we are focused on the right members, the right types of gaps in coding and care, how much we have improved the accuracy and completeness of diagnostic data, what opportunities remain, and estimate the value of those opportunities to drive risk adjustment strategy and mitigate risk.
- Provides analytic and measurement support to inform pilot test/intervention design; ensures rigor in outcomes evaluation; evaluates pilot tests/interventions with respect to gap closure and ROI; and informs decisions about pilot/intervention modification and scale-up.
- Provides provider-focused analytics and reporting; provides summary report of provider performance on gaps in coding and care delivery.
- Analyzes complex data and information to provide meaningful results, identify success factors and improvement opportunities, suggest potential solutions, and help internal customers set strategic directions.
- Keeps abreast of current and new business content, regulatory knowledge, best practices, analytical methods and knowledge of diverse data sources-and systems necessary to support the efforts of Risk Adjustment analytics initiatives.
- Communicates complex Risk Adjustment concepts, strategies, initiatives, analytics, and results to a variety of stakeholders, including senior leadership.
- Reports results on risk adjustment-related outcomes, identifies needs and opportunities for improvement, and interprets results for stakeholders.
- Develops and manages relationships with other analytic teams and leaders at VNS Health Plans to share best practices across the organization.
- Performs all duties inherent in a supervisory role. Ensures effective staff training, interviews candidates for employment, evaluates staff performance, and recommends hiring, promotions, salary actions and terminations, as appropriate.
- Participates in special projects and performs other duties as required.
Qualifications
Education: Bachelor’s degree in Business, Finance, Actuarial Science, Quantitative Social Science, Mathematic, Statistics, Computer Science or a related field required. Master’s degree preferred.
Certifications: SAS Certification or any certification I Advanced Analytics or Machine learning/Deep Learning or a related topic preferred.
Experience: Minimum of four years of progressive experience in healthcare or risk adjustment data analysis required.
Experience modeling data involving outcomes and utilization, using various statistical software and computer programming (SAS, SQL, R, etc.) required. Demonstrated ability to evaluate quantitative data from multiple sources using statistical analysis and critical thinking skills required. Demonstrated experience with statistical software suites (e.g., SAS, R, Stata), strong understanding of database structure, relational database concepts, and exposure to Unix environments required. Ability to define problems, collect data, establish facts, and draw valid inferences required.
Strong problem-solving skills exhibited by the ability to approach complex, ambiguous business issues with creative ideas and solutions required. Demonstrated strong communication, facilitation, and presentation skills required.
Demonstrated experience in collaboration, teamwork, and cross-functional communication required. Familiarity with health policy, health insurance, benefit plans and product features, provider contracting approaches, reimbursement approaches and health management approaches required. Demonstrated strong organizational and project management skills, including the ability to handle multiple concurrent assignments, required. Experience programming using risk adjustment models for Medicare, computing risk scores and evaluation of risk scores output for quality preferred. Prior experience in risk adjustment activities in a Medicare, Affordable Care Act or provider organization to including submission of Risk Adjustment Processing System (RAPS), and (Encounter Data Processing System (EDPS), responses and reconciliation per CMS and other State and Federal Guidelines preferred. Knowledge of claims coding and payment methodology, associated with a Health Plan domain preferred. Background in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) Methodologies preferred.
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