Healthcare Risk Management Analyst

2 weeks ago


Rochester, New York, United States Excellus BlueCross BlueShield Inc Full time

Position Title: Risk Adjustment Analyst I/II/III/IV

Job Category: Non-Manager

Overview: The Risk Adjustment Analyst plays a crucial role in delivering analytical and data-driven services aimed at enhancing risk-adjusted revenue. This position ensures adherence to compliance standards set by CMS and NYS while evaluating the financial implications of modifications in risk adjustment data and methodologies.

Key Responsibilities:

  • Collaborate with coding and analytical teams across various regions, as well as with vendors and internal departments including Finance, Actuarial, Operations, and Compliance.
  • Develop financial forecasts and conduct analyses for risk adjustment initiatives, including retrospective chart reviews and prospective projects.
  • Aggregate, standardize, and consolidate financial claims, membership, and premium data into comprehensive datasets for analytical and reporting purposes.
  • Utilize industry resources to enhance knowledge and improve the return on investment (ROI) of risk adjustment activities.
  • Maintain up-to-date knowledge of risk adjustment models, including CMS Hierarchical Condition Categories (HCC), RxHCCs, HHS HCCs, and Clinical Risk Groups (CRGs).
  • Calculate ROI for risk adjustment vendors and initiatives, assisting in the preparation of detailed analyses.
  • Generate ad hoc reports to support risk adjustment processes through effective query building and data extraction.
  • Provide support to other Risk Adjustment teams or Health Plan departments as needed.
  • Stay informed about relevant legislative and regulatory mandates to ensure compliance in all activities.

Qualifications:

We offer multiple levels of classification based on demonstrated knowledge, skills, and the ability to manage increasingly complex assignments. A Bachelor’s degree in Math, Economics, Actuarial Science, Computer Science, or a related field is required, along with a minimum of one year of relevant experience. Alternatively, actuarial exams, technical certifications, or programming coursework may be considered in lieu of experience.

Skills Required:

  • Exceptional analytical abilities with strong verbal and written communication skills.
  • Proficient organizational skills with the capacity to prioritize and multitask in a fast-paced environment.
  • Comprehensive understanding of health insurance products, managed care, and accounting principles.
  • Self-motivated with the ability to work independently under minimal supervision.
  • Strong computer skills, particularly in Microsoft Office Suite and familiarity with data integration tools.

Preferred Qualifications:

  • Experience with programming languages such as SAS, SQL, R, Python, or similar.
  • Familiarity with medical claims and terminology.
  • Advanced knowledge of risk adjustment models.

This position is an equal opportunity employer and is committed to diversity and inclusion in the workplace.



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