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Risk Adjustment Analyst
2 months ago
PacificSource Administrators, Inc. is seeking a highly skilled Risk Adjustment Analyst to join our team. As a Risk Adjustment Analyst, you will play a critical role in ensuring the accuracy and completeness of data submissions to regulatory entities, such as the Centers for Medicare & Medicaid Services (CMS).
Key Responsibilities- Recommend and guide process improvements to optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden.
- Identify, analyze, interpret, and communicate risk adjustment trends to provider partners and related entities.
- Maintain existing reports, develop new reports, and provide ad-hoc data analysis to support company goals.
- Lead internal subject matter experts in regular meetings to identify and rectify data submission and adjudication errors related to risk adjustment data submission.
- Develop and maintain data sets leveraging internal data, regulatory entity responses, and ancillary data sources.
- Demonstrate proficiency in running applicable risk models, including CMS models for Medicare Advantage members and the HHS model for Commercial ACA members.
- Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission, and error resolution.
- Assist with audits, including RADV, through preparation activities and documentation.
- Assist in developing, maintaining, and reporting actionable metrics related to risk adjustment and incorporating quality/health outcome metrics.
- Collaborate with internal and external partners to resolve data issues related to member, claim, provider, and pharmacy data and processes.
- Three years of experience in data analytics related to health information required.
- Experience in a Health Plan preferred.
- In-depth Medicare or Commercial ACA risk adjustment experience required, including risk model and CMS guidelines, RAPS/EDS & EDGE data submissions, retrospective and prospective programs, and RADV audits.
- Expertise in Microsoft Excel and SAS/SQL required.
- Experience in leading projects and project teams preferred.
- Medicaid risk adjustment experience preferred.
- Familiarity with Risk Adjustment Documentation and Coding practices preferred.
- Medicare Stars and/or HEDIS experience preferred.
- Bachelor's degree in Mathematics, Statistics, or a similar research-related field required.
- Advanced degrees preferred.
- Adaptability
- Building Customer Loyalty
- Building Strategic Work Relationships
- Building Trust
- Continuous Improvement
- Contributing to Team Success
- Planning and Organizing
- Work Standards
Work inside in a general office setting with ergonomically configured equipment. Travel estimated to be 10% of the time.
