Senior Healthcare Risk Analyst

2 weeks ago

Boise, Idaho, United States PacificSource Administrators, Inc. Full time

Position Overview: The Senior Risk Adjustment (RA) Analyst plays a crucial role in ensuring precise and thorough data submissions to regulatory bodies, including the Centers for Medicare & Medicaid Services (CMS), for all populations subject to risk adjustment. This role utilizes available tools and expertise in relevant risk models to enhance data submissions related to Hierarchical Condition Categories (HCCs) and other relevant data within the system. The Senior RA Analyst will work collaboratively with both internal and external stakeholders to reduce submission errors, oversee vendor partnerships, compile and present essential data sets, refine processes associated with risk adjustment, maintain necessary documentation, and ensure adherence to all relevant laws, guidelines, and regulations. This includes engaging with provider partners to inform them about performance metrics and educate them on best practices in risk adjustment. Additionally, the Senior RA Analyst will mentor junior team members and influence leadership decisions by providing recommendations for potential enhancements to risk adjustment processes and outcomes.

Join PacificSource and contribute to our mission of providing quality, affordable healthcare.

PacificSource is an equal opportunity employer. All qualified candidates will be considered for employment without regard to protected veteran status, disability status, or any other protected status, including race, religion, color, national origin, sex, sexual orientation, gender identity, or age.

Diversity and Inclusion: At PacificSource, we value the diversity of our workforce and the communities we serve. We are dedicated to fostering an inclusive environment where individual differences are recognized, respected, and leveraged to fully develop and utilize each person's talents and strengths.

Key Responsibilities:

  1. Recommend and implement process enhancements to optimize risk adjustment factor increases while minimizing inaccuracies in disease burden capture.
  2. Analyze, interpret, and communicate risk adjustment trends to provider partners and relevant entities.
  3. Maintain existing reports and develop new ones to ensure alignment with company objectives, along with addressing ad hoc requests as necessary.
  4. Lead internal subject matter expert meetings to identify and resolve various data submission and adjudication errors related to risk adjustment.
  5. Develop and manage data sets utilizing internal data, regulatory response data (such as EDGE files, MMR, MOR, RAPS Response, MAO-004, etc.), and additional data sources for enterprise-wide consumption.
  6. Exhibit proficiency in executing all relevant risk models, including various CMS models for Medicare Advantage members and the HHS model for Commercial ACA members.
  7. Oversee vendor partnerships through analytic reconciliations to ensure compliance with regulations, optimal data submissions, and accurate error resolution.
  8. Assist with audits, including RADV, through preparation and documentation activities.
  9. Conduct root cause analyses to uphold data integrity and processes, minimizing discrepancies and gaps.
  10. Stay informed about current CMS regulations and announcements impacting risk adjustment, including attending educational sessions and pursuing industry learning opportunities.
  11. Develop, maintain, and report actionable metrics related to risk adjustment, incorporating quality and health outcome metrics where applicable.
  12. Support projections of annual receivable amounts, pricing efforts, and cost utilization predictions related to risk adjustment.
  13. Coordinate internal releases and modifications in response to changing data and file specifications through approved procedures.
  14. Collaborate with internal teams, provider partners, and vendors to resolve data issues concerning member, claim, provider, and pharmacy data and processes.
  15. Provide mentorship, leadership, and training to less experienced risk adjustment analysts.

Supporting Responsibilities:

  • Meet departmental and organizational performance and attendance standards.
  • Adhere to PacificSource privacy policies and HIPAA regulations regarding the confidentiality and security of protected health information.
  • Perform additional duties as assigned.

Work Experience: A minimum of five years of experience in data analytics is required, including at least three years in a Health Plan setting. Extensive experience in Medicare and Commercial ACA risk adjustment is essential, covering risk models, CMS guidelines, RAPS/EDS & EDGE data submissions, retrospective and prospective programs, and RADV audits. Proficiency in Microsoft Excel and SAS/SQL is required, along with experience in leading projects and project teams. Familiarity with Medicaid risk adjustment is necessary, while knowledge of Risk Adjustment Documentation and Coding practices is preferred. Experience with Medicare Stars and/or HEDIS is also advantageous. Equivalent work and educational experience will be considered.

Education, Certificates, Licenses: A Bachelor's degree in Mathematics, Statistics, or a related research field is required; advanced degrees are preferred.

Knowledge: Strong analytical and problem-solving skills are essential. Mastery of computer programming theories and applications is required, with SAS and VBA being the primary tools utilized. The ability to stay current with evolving technologies, work independently with limited supervision, exercise initiative within established guidelines, and prioritize tasks to meet deadlines is crucial. Excellent verbal and written communication skills are necessary for presentations and documentation. The ability to establish and maintain effective working relationships, demonstrate good judgment, and exhibit creativity is vital. Candidates must be able to read, comprehend, and interpret complex documents.

Competencies:

  • Adaptability
  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Building Trust
  • Continuous Improvement
  • Contributing to Team Success
  • Planning and Organizing
  • Work Standards

Environment: Work is conducted in a general office setting with ergonomically configured equipment. Travel is estimated to be 10% of the time.

Our Values: We are guided by our core values, which drive our business practices:

  • Commitment to integrity.
  • Collaboration towards common goals.
  • Responsibility for customer service.
  • Open communication at all levels.
  • Active participation in community improvement.
  • Advancement of social justice, equity, diversity, and inclusion.
  • Encouragement of creativity, innovation, and excellence.

Physical Requirements: The role involves stooping and bending, sitting and/or standing for extended periods, repetitive motions such as typing, sorting, and filing, as well as light lifting and carrying of files and materials. Candidates must be able to read and comprehend both written and spoken English and communicate effectively.

Disclaimer: This job description reflects the general nature and level of work performed by employees in this position.

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