Risk Adjustment Consulting, Consultant

2 weeks ago

Philatelic, United States Blue Shield of California Full time

Your Role

The ACA Chart Program team conducts the following functions (1) identify medical records with unreported diagnosis codes, (2) retrieve those medical charts, (3) perform medical coding to convert them into risk adjustable diagnosis codes, and (4) submit to CMS via the EDGE pathway. The Risk Adjustment, Consultant will report to the Senior Manager. In this role you will manage day to day operations of the chart program, conduct risk adjustment analytics to identify drivers and interact with vendor to ensure adherence to key performance indicators.

Your Work

In this role, you will:

  • Make recommendations based on understanding the core principles and functionality of decision, descriptive, predictive, and prescriptive analytic methods
  • Train lower-level analysts on how to update and apply these advanced analytic techniques
  • Drive leadership, guidance, and manage all aspects of a given program, including vendor oversight, internal cross-functional partnerships, tracking performance and measuring results
  • Manage complex data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
  • Manage the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs
  • Assist in generating chart chase lists, manage retrieval of ACA charts with vendor, track chart coding and validations, assist in the preparation of XML submissions to EDG server
  • Possess strong project management skills with minimum guidance. Adept at creating timelines and staying on track on projects. Provide heads-ups to leadership when roadblocks appear
  • Conduct Chart ROI management (drive to root cause analysis and manage mitigation plans).
  • Provide clear communication with clear takeaways and analytic insights

Your Knowledge and Experience

  • Requires a bachelor’s degree or equivalent experience
  • Requires at least 6 years of professional experience
  • Requires experience with ACA or MA Risk adjustment concepts desired
  • Requires operational background to manage processes, vendor, and staff
  • Requires experience in assessing trends and patterns in a population datasets using SAS / SQL
  • Requires ability to create new data analytic processes in SAS/SQL
  • Requires ability to run, and debug existing complex data-analytic processes in SAS/SQL.
  • Requires ability to validate new and existing data analytic processes, in context of broader enterprise objectives
  • Requires ability to juggle multiple complex tasks simultaneously and message clearly to dependent party when one task is slipping relative to another
  • Program management skills, along with related ability to rapidly diagnose root-cause of analytic problems preferred

Pay Range:

The pay range for this role is: $ 118800.00 to $ 178200.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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