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CareFirst BlueCross BlueShield · 1 day ago

Senior Risk Adjustment Analyst - Business Ops (Hybrid)

Baltimore, MD

Full-time

Hybrid

Mid, Senior Level

$64K/yr - $127K/yr

5+ years exp

CareFirst BlueCross BlueShield is a health insurance provider, and they are seeking a Senior Risk Adjustment Business Operations Analyst. The role involves ensuring the accuracy of risk adjustment performance metrics, coordinating analytical processes, and providing support for various Medicare and Medicaid programs.

Health CareNon ProfitService Industry

No H1B

Responsibilities

Maintain the Business Operational Plan for risk adjusted segments to support audit readiness. Update, create and maintain business process and technical workflow documents. Monitor and reconcile Business Policies and Procedures as mandated by LOB. Maintain dashboards and reporting delivering results of analyses to improve awareness and understanding of risk adjustment and identification of member health conditions

Understand CMS risk score methodology, including risk score calculation, financial risk calculations, submission processes and key regulatory deadlines for data submission. Understand the impact of the claims on the risk adjustment revenue including interpretation of HHS/CMS/Medicaid guidelines, monitoring and determining the impact of any changes to the model and supporting team in planning for changes

Assists in designing an overall suite of analytic capabilities and actionable reports to monitor internal performance, oversee vendors, 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 & complete reimbursement based on the applicable model. Perform data mining of claims and data to identify trends, data issues

Support project & program 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

Qualification

Data analysisRisk score methodologySASSQLRegulatory complianceStatistical methodsPoliciesProceduresAnalytical abilitiesVBAMS AccessProblem-solving

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

Deep knowledge of regulatory compliance and risk adjustment program integrity

Experience developing & maintaining policies and procedures

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

Experience with EDGE, EDPS & MA 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