Manager, Risk Adjustment Modeling

3 weeks ago

Rochester, New York, United States Univera Healthcare Full time

Job Description:

Summary:

The Manager, Risk Adjustment Modeling is responsible for the creation and maintenance of risk adjustment data models, including the CMS HCC, HHS HCC and NYS 3M CRG models, for the purpose of understanding current risk scores for risk adjustable populations, validating revenue from State and Federal sources, analyzing the impact of internal initiatives and external actions, and forecasting the trend of risk scores based on market and regulatory forces. Collaborates with risk adjustment leadership and internal departments on the development of strategy to ensure member risk scores accurately reflect their burden of illness. Responsible for supervising a team of data analysts and the development of those analysts.

Essential Primary Responsibilities/Accountabilities:

  • Manages the development, routine maintenance and continual improvement of a CMS HCC model for Medicare Advantage Part C and D, utilizing RAPS and EDPS data sources, CMS files (MMR, MOR, TRR, etc.) and other internal and external data sources.
  • Manages the development, routine maintenance and continual improvement of an HHS HCC model for ACA Commercial products, utilizing EDGE reports and other internal and external data sources.
  • Manages the use of and access to the 3M CRG model, increasing understanding of the model and integrating results with internal models and data sources.
  • Evaluates success of risk adjustment initiatives, and opportunity or recovery of any internal work efforts, by assigning dollar value to risk score lift on all programs.
  • Develops reporting dashboards which display risk score trends and impact from internal initiatives and external actions to support executive decision making and inform strategy development.
  • Collaborates with Accounting and Actuarial departments to reconcile payments & risk adjusted revenue from all state and federal sources, ensuring risk score calculations agree between internal models and regulators.
  • Advises internal departments on the use and interpretation of risk scores and associated reports and datasets to enhance understanding and risk adjustment literacy within the enterprise.
  • Supports Care Management and Utilization Management by using risk adjustment data to provide additional insight on members' burden of illness.
  • Collaborates with Data Science and Analytics & Data Divisions on risk adjustment data inputs to predictive modeling.
  • Mentorship and development of staff.
  • Prepares and maintains documentation for routine procedures and special projects and supports departmental and enterprise policies and procedures.
  • Establishes individual annual performance goals for staff, guides staff in setting individual learning and development plans, assesses individual performance, and determines merit, promotional and recognition salary increases and awards.
  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
  • Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
  • Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
  • Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
  • Regular and reliable attendance is expected and required.
  • Performs other duties and functions as assigned by management.

Minimum Qualifications:

  • Bachelor's degree in Actuarial Science, Mathematics, Statistics, Information Management, Accounting, Finance or related field
  • 5 years of experience in healthcare industry and 3 years with data analysis required
  • 2 years of supervisory experience or leadership of projects, processes, or relationships required
  • Advanced Analytics skills
  • Ability to understand and work with programming languages similar to SAS, SQL, R, Python, Java, C/++/#, VB, etc.
  • Base or Advanced SAS Certifications desirable.
  • Knowledge of CMS HCC, HHS HCC and CRG models, familiarity with RAPS, EDPS, EDGE and APD submission systems.
  • Strong verbal and written communication skills
  • Ability to design and implement process improvements.
  • Strong project and people management skills.
  • Ability to translate technical concepts into business language.
  • High integrity and interpersonal skills.
  • High sense of urgency and accountability.
  • High degree of independence, creativity and initiative.

Physical Requirements:

  • Works from a desk most of the time

The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Grade 210A: Minimum $85,446 - Maximum $183,394

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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