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CareFirst BlueCross BlueShield · 17 hours ago

Senior Risk Adjustment Analyst- Medicare Encounters (Hybrid)

Baltimore, MD

Full-time

Hybrid

Mid, Senior Level

$64K/yr - $127K/yr

5+ years exp

CareFirst BlueCross BlueShield is seeking a Senior Medicare Encounters Risk Adjustment Analyst who will ensure the accuracy and integrity of key risk adjustment performance metrics. The role involves complex data analysis, collaboration with stakeholders, and support for risk adjustment programs and initiatives.

Health CareNon ProfitService Industry

No H1B

Responsibilities

Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are being addressed in a timely manner with interface with departments to improve and correct data. Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy and identification of member health conditions. Update, create and maintain business process and technical workflow documents

Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDPS processes and key regulatory deadlines for data submission. Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue

Assists in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance. Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in accurate reimbursement based on the CMS-HCC (Hierarchical Condition Code) model. Perform data mining of claims and data to identify trends, data issues and members with missing HCCs

Support project management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support management 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. Work with team members to understand and monitor the financial impact of risk adjustment programs. Contribute to developing materials and presenting key updates to leadership regarding risk adjustment programs and provider and member engagement initiatives

Qualification

SASSQLRisk score methodologyStatistical analysisVBAMS AccessAnalytical abilitiesProblem-solvingCollaborationCommunication

Required

Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience

5 years experience with data analysis which includes use of statistical methods, experience with programming language

Experience with SAS, SQL, VBA or other programming language and MS Access Database

Experience with EDGE & ACA or Medicaid risk score methodology, including risk score calculation and financial risk receivable calculations

Excellent analytical and problem-solving abilities

High level statistical abilities

The ability to work independently and with those in various departments and areas not directly reporting to the Division

Ability to work with and support Senior Management and to disseminate and summarize information into a format that can facilitate high-level decision-making process