Job Location: Manhattan
Overview
Performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies. Collaborates regularly with internal departments and external vendors on risk adjustment projects. Gathers, standardizes and consolidates financial claims, membership and premium data into data sets used for risk adjustment analytical and reporting needs. Leverages industry resources to increase knowledge and improve ROI of risk adjustment activities. Builds understanding of risk adjustment models in emerging business areas, including Medicaid. Works under general supervision.
Responsibilities
- Performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies.
- Collaborates regularly with internal departments, including Finance, Medicare Operations, Network Management, Provider Contracting, and Health Economics, and external vendors on risk adjustment projects. Calculates ROI for risk adjustment vendors, initiatives and projects.
- Gathers, standardizes and consolidates financial claims, membership and premium data into data sets that are used for risk adjustment analytical and reporting needs. Develops regular and ad hoc reports to supplement risk adjustment processes through query building and data extraction, including monthly risk adjustment revenue accruals.
- Leverages industry resources to increase knowledge and improve ROI of risk adjustment activities. Builds understanding of risk adjustment models in emerging business areas, including Medicaid.
- Maintains current knowledge of CMS’ Hierarchical Condition Categories (HCC) and Prescription Drug Risk Adjustment codes (RxHCCs) including risk adjustment values and formulas.
- Supports response to Risk Adjustment Data Validation (RADV) audits by preparing analytics.
- Leads risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff. Assists in performing analyses used in the development of financial plans, re-forecasts, and other financial projections.
- Performs data mining functions and identifies trends in data. Informs Actuarial leadership of findings and collaborates to create predictive models using information obtained from mining, and to provide decision support.
- Works with the PMO and the product managers to provide insights into the current state of operations and identify gaps and opportunities for improvement.
- Works on identifying gaps in the claims, encounter reconciliation process, and provides insights to educate providers to improve billing practices.
- Builds reports and dashboards to track risk adjustment related projects and track the effectiveness of the initiatives.
- Participates in special projects and performs related duties as assigned.
Qualifications
Education:
- Bachelor’s degree in Information Management, Statistics, Healthcare Informatics, Public Health or related field with equivalent knowledge required.
- Master’s in health related field or informatics preferred.
Experience:
- Minimum five years of increasingly responsible data analysis experience in a healthcare setting required.
- Prior experience with Medicare Advantage Risk Adjustment required. Knowledge of MLTC, Medicare Advantage and Medicaid required.
- Familiarity with medical claims and medical terminology preferred.
- Proficiency in personal computer programs including MS Excel (including formulas, sorts, filters, pivot tables, IF statements, VLOOKUP, HLOOKUP, etc.), Access (criteria statements, table links, and database and report creation), and Word, required.
- Understanding of basic principles and design of data warehousing required.
- Experience with relational databases and programming experience in SQL or PL/SQL required.
- Proficiency conducting statistical analysis with R or Python required.
- Effective oral, written, and interpersonal communication skills are required.
- Ability to multi task in a fast-paced environment required.
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