Risk Adjustment Data Analytics Manager

2 months ago

Springfield, United States Health New England Full time
Job DescriptionJob Description

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

Summary: Provide a brief summary of the purpose of this role. Include the role’s primary responsibility, its impact on end results, and the degree of freedom to act.


The Risk Adjustment Data Analytics Manager is responsible for leading the analytics team and providing insights that drive business decisions. They will work closely with each Risk Adjustment lane to understand business objectives and develop analytics solutions that deliver value. The Risk Adjustment Data Analytics Manager is a leadership role that is responsible for supporting the Risk Adjustment Department in regulatory submissions, performance reporting, investigative analytics, and technology solutions. This position is responsible for supporting the successful submission of all Risk Adjustment data, solutions, and processes to ensure quality and timely submissions, error resolution, and risk model updates. This positions also supports Risk Adjustment programs through the metric development, data modeling, investigative analytics, reporting, implementation, and coordination of initiatives and operational programs related to HNE’s Risk Adjustment strategies. The Risk Adjustment Data Analytics Manager leads Risk Adjustment data analytics and reporting, as well as data submissions, reconciliation, and validation. This role also supports operations and teams through provider reporting, patient risk stratification and resource prioritization, data integrity, and acts as the primary liaison for Risk Adjustment data and reporting.

Essential Functions: List in order of importance the essential duties and responsibilities of this role, and estimate the percentage of time spent on each. Include management and supervisory responsibilities, if any.


Program Management – 80%
  • Lead the analytics and reconciliation team and ensure that all team members have the resources and support they need to meet objectives and succeed
  • Develop and implement an analytics strategy that aligns with business objectives
  • Lead efforts to analyze data and generate insights, reports, and recommendations to support business decisions
  • Manages all encounter submissions to vendors and regulatory bodies
  • Accountable for accuracy and validation of all submissions, Risk Adjustment Metrics, and Provider Reporting
  • Manages and develops interventions to reconcile encounter submissions to minimize errors and data loss and perform root cause analysis
  • Manages vendor transmissions, including membership, encounter, provider, and custom reporting
  • Collaborates with Risk Adjustment program team to update, track, and report key performance indicators for all Risk Adjustment programs and processes through reporting and dashboard development
  • Interprets data trends and outcomes and provides recommendations to improve strategies
  • Works collaboratively with internal HNE teams and resources to support vendor management
  • Collaborates on development of new programs and initiatives to support Risk Adjustment strategies
  • Interprets and provides insight and impact to HNE on regulatory updates to Risk Adjustment reimbursement methodologies
  • Identifies educational opportunities through data analysis and benchmarking
  • Collaborates in identifying targets for improvement and evaluates the results of interventions
  • Manages all reporting, ROI estimates, and performance outcomes in evaluating effectiveness of RA strategies
  • Reviews and evaluates team performance for productivity
  • Collaborates with internal resources to automate transmissions, reporting, and identifies other areas of opportunity to automate
  • Assists in setting priorities for Risk Adjustment Reconciliation team
  • Coordinates the orientation of new teammates
  • Participates in process improvement projects
  • Performs additional duties as assigned

Ad-hoc Analysis and Reporting Support – 20%
    • Provides support for ad -hoc clinical, financial, regulatory, pharmacy and operational reporting requests.
    • Supports the performance of investigative analytics and root cause analysis in support of improving performance outcomes
    • Develops and maintains quality controls and validation reporting for relevant Risk Adjustment activities, submissions, and reports.
    • Prepares presentations, reports, process documentation, for internal and external stakeholders to support successful programmatic outcomes.
    • Acts as a resource for other members of the department on technical issues and identify ways to leverage technology, processes, and tools to solution for desired program outcomes.

Minimum Requirements: State the specific knowledge, skills, abilities, and experience required to perform the essential functions listed above. Include particular degrees, licenses, certifications, etc. if they are a minimum requirement for the job.


Bachelor’s degree with a minimum of three (3) years of healthcare analytics, risk adjustment, project management, or technologies.

    • Strong analytics and problem solving skills
    • Proficiency in statistical analysis and data visualization tools and platforms
    • SQL, Python, R, SAS, SPSS, or related proficiency
    • Experience in working with large, complex, disparate data sets
    • Experience with Risk Adjustment methodologies
    • Experience with claims, clinical, and/or financial data
    • Experience with data interpretation, analysis, visualization, and reporting
    • Experience with clinical documentation, medical records, and electronic medical record systems
    • Knowledge of managed care and health care claims
    • Knowledge of Risk Adjustment models (e.g. CMS Medicare Advantage, HHS-HCC, Medicaid DxCG)
    • Intermediate to advanced MS Word, Powerpoint, and Excel skills
    • Excellent oral and written communication skills
    • Excellent presentation skills
    • Ability to develop and execute projects and meet deadlines

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