Risk Adjustment Analyst Sr

5 days ago

Atlanta, Georgia, United States Baylor Scott & White Health Full time
Job Summary

The Risk Adjustment Analyst Sr (Texas Medicaid Encounter Analyst) is responsible for overseeing the end-to-end encounter management workflow. This role supports program management activities around risk adjustment data management and submissions to government agencies such as Centers for Medicare and Medicaid Services (CMS) or Health & Human Services (HHS).

Key Responsibilities
  • Monitor and oversee the end-to-end claims encounter management workflow.
  • Analyze claims and supplemental data to identify reporting gaps, risk gaps, or sources of incorrect and incomplete diagnostic data.
  • Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines.
  • Using data from internal and external sources, analyze complex encounter inbound/outbound process issues to provide insight to decision-makers.
  • Research and document encounter errors in established systems and databases with appropriate statistical trend analysis; perform root cause analysis of encounters processing and submission issues and develop recommendations based on data and industry standards.
  • Perform various financial analysis such as revenue forecasting and ROI.
  • Contribute to program improvement by designing and implementing business process and system changes, collaborating to resolve encounter data and process issues and managing policy and procedure documentation.
Requirements
  • Advanced knowledge of SQL, MS Excel, MS Access, MS Word, MS Visio, and MS PowerPoint.
  • Ability to design and run intermediate to complex queries and reports from multiple databases using SQL.
  • Ability to independently gather, interpret, and analyze data for the purpose of identifying trends, problems, and opportunities for improvement.
  • Excellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.
  • Able to work under pressure, adhere to deadlines, and know when to escalate information and issues.
  • Highly motivated and able to work with minimal guidance, independently and as a team participant.
  • Outstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.
  • Ability to work in a high-paced environment independently and with cross-functional groups.
  • Knowledge of ACA, Medicare, Medicaid, MCO, TPA business requirements preferred.
  • Experience with healthcare encounters, enrollment, and pharmacy data preferred.
Benefits

Our competitive benefits package includes:

  • Immediate eligibility for health and welfare benefits.
  • 401(k) savings plan with dollar-for-dollar match up to 5%.
  • Tuition Reimbursement.
  • PTO accrual beginning Day 1.

Note: Benefits may vary based upon position type and/or level.

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