Risk Adjustment Optimization Expert

2 weeks ago


Lakewood, United States Blue Shield of California Full time
Job Summary

We are seeking a highly skilled Risk Adjustment Consulting professional to join our team at Blue Shield of California.

Company Overview

As a leading health plan, Blue Shield of California is committed to delivering high-quality healthcare services to our members. Our Risk Adjustment Provider Partnership team plays a critical role in ensuring accurate and compliant risk adjustment data submission.

In this role, you will work closely with operational and clinical leaders to improve recapture rates, understand clinical suspects, and monitor documentation and coding accuracy. You will also implement Blue Shield programs that ensure diagnoses are coded according to CMS and risk adjustment guidelines.

Responsibilities
  • Program Development and Implementation: Drive leadership and manage all aspects of a given program, including vendor oversight, internal cross-functional partnerships, tracking performance, and measuring results.
  • Data Analysis and Management: Manage 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.
  • Collaboration and Training: Collaborate with provider groups to enhance their risk adjustment processes by creating tailored plans to boost RAF performance and improve coding specificity. Train lower-level staff on how to update and apply advanced analytic techniques.
Requirements

To be successful in this role, you will require:

  • A bachelor's degree
  • At least 6 years of professional experience
  • Deep knowledge of job area obtained through professional experience and advanced education
  • Knowledge of ICD-10 codes, Risk Adjustment models, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management, and/or provider network management areas of a healthcare-related company
  • Proficiency in Excel, Word, PowerPoint, and Outlook
Compensation

The estimated salary for this role is between $118,800.00 and $178,200.00 per year, based on location and experience.

Please note that salaries at Blue Shield are based on a variety of factors, including candidate experience, location, and current employee salaries for similar roles.



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