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Risk Adjustment Analyst

Company: Oculus Search Partners
Location: Hempstead
Posted on: November 12, 2021

Job Description:

Position Summary: The Risk Adjustment Analyst will support revenue program management activities around data management and submissions to CMS. Serve as a subject matter expert to management and stakeholders around end-to-end process of data management, data processing, data analysis and submissions. Interface with different business areas on the execution of data submissions, identifying and applying best practices and processes to ensure efficiency and accuracy of end-to-end operation of risk adjustment programs. Identify and recommend both strategic and tactical improvements, and contribute to compliance to all applicable laws, guidance, and regulations. Develop and sustain a long-term optimal structure and processes around emerging encounter data submission requirements; analyzing, monitoring, and planning key risk adjustment milestones and identifying and recommending opportunities for improvement. Assist in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance. Work closely with end-users to gather reporting requirements and analyze internal reporting tools; to ensure proper testing and validation of data elements on the finished product; to participate in the resolution of reporting problems; to build, perform, and maintain reporting analysis and modeling; to provide analytical support on various strategies to ensure organizational goals are met; to propose opportunities in maximizing reimbursement based on the CMS HCC model and the CRG model; to propose innovative approaches to create or improve automation and optimize processes data and analytic processes as well as reporting; and to lead cross-functional analytical and operational teams toward the goal of improved risk adjustment scores. Essential Position Functions/Responsibilities:
Data Management & Submissions: -- Partner with other business units to deliver requirements around necessary updates to underlying data and systems as used by the Risk Adjustment and Coding departments. -- Recommend, develop, and monitor processes around data collection, submission, and reconciliation to ensure full compliance with all applicable laws, guidance, and regulations. Provide detailed reporting and oversight for data submission activities. Partner to develop dashboards to report progress with sponsors and escalate issues with key stakeholders. -- Understand CMS risk score methodology, including risk score calculation, key regulator deadlines for data submission, understand eligibility, claims, and provider data. -- Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are addressed in a timely manner. Interface with Quality, Finance, IT, Provider, Claims, Business Intelligence, and other company teams to improve and correct data. -- Analyze data flow and data integrity to identify areas for improvement in risk adjustment scores. -- Complete routine quality assurance checks to ensure data accuracy and completeness and execute corrections as needed. -- Update, create, and maintain business process and technical workflow documents. Analytics: -- Operate risk adjustment analytic vendor platforms to assist with intervention tracking, monitoring, analysis and reporting of diagnosis codes that drive risk adjusted payments. -- Oversee the analysis and interpretation of provider-specific results and risk score trend information; to improve awareness and understanding of risk adjustment results and the quality, accuracy and identification of member health conditions. -- Assist the Risk Adjustment Manager in providing company teams with appropriate tools, resources, and reports to help achieve success with downstream providers. -- Conduct analyses to develop a comprehensive understanding of a provider---s risk score trends -- Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support the Risk Adjustment Manager in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved. -- Collaborate across business units to coordinate the development of financial dashboards and models to identify and track revenue and ROI trends. -- Contribute to developing materials and presenting key updates to the company's leadership regarding risk adjustment programs and provider and member engagement initiatives. Qualification Requirements:
Skills, Knowledge, Abilities -- Advanced proficiency in SQL (required). -- Intermediate proficiency in MS Excel (required). -- Direct experience with relational databases and knowledge of query tools. -- Ability to manage projects and project plans within stated time lines. -- Ability to communicate effectively, and work well in a team oriented environment. -- Resourceful and creative in solving complex issues and working corroboratively with others. Training/Education: -- Bachelor or Associate degree in Health Administration, Business, Economics, Health Informatics, or related field required. Or equivalent experience. Experience: -- A minimum of 5 years--- experience in managed care or other healthcare environment in an analyst role. -- Direct experience with CMS HCC risk adjustment methodology (required). -- Direct experience with encounter data submission processes (required). -- Direct experience utilizing risk adjustment analytic vendor platforms (required).

Keywords: Oculus Search Partners, Hempstead , Risk Adjustment Analyst, Professions , Hempstead, New York

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