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PacificSource Health Plans · 1 day ago

Senior Risk Adjustment Analyst

Bend, OR

Full-time

Onsite

Mid, Senior Level

$75K/yr - $127K/yr

5+ years exp

PacificSource Health Plans is seeking a Senior Risk Adjustment Analyst to help their members access quality, affordable care. The role involves optimizing data submissions to regulatory entities, collaborating with internal and external partners, and ensuring compliance with applicable laws and regulations while providing mentorship to less experienced team members.

CommunitiesCustomer ServiceNon Profit

H1B Sponsor Likely

Responsibilities

Recommend and guide process improvements that will optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden

Identify, analyze, interpret and communicate risk adjustment trends to be consumed by provider partners and related entities

Responsible for maintenance of existing reports, development of new reports to help ensure company goals are met, as well as other ad hoc requests as needed

Develop and maintain reporting capabilities to measure and forecast risk scores & quality metrics, monitor suspecting model performance, and identify areas of improvement

Maximize risk adjustment revenue and quality bonus payments by driving data integration and analytics to properly capture and improve the health status of PacificSource members

Validate data integrity and collaborate with technical teams to improve data pipelines and business logic for identified areas of opportunity

Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment and quality data submission

Develop and maintain data sets leveraging internal data, response data from regulatory entities (including but not limited to: EDGE files, MMR, MOR, RAPS Response, MAO-004, PSV, PLD, etc.), and ancillary data sources to be consumed across the enterprise

Demonstrate mastery in running all applicable risk models including the various CMS models for Medicare Advantage members, the HHS model for Commercial ACA members, and others as needed

Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy

Assist with all pertinent audits, including RADV, through preparation activities and documentation. Perform root cause analysis to maintain high integrity data and processes to minimize discrepancies and gaps

Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings. This includes review of regulatory announcements, attending educational sessions and opportunities provided by regulatory entities or within the industry

Develop, maintain, and report out on actionable metrics related to risk adjustment and HEDIS ® to incorporate quality/health outcome metrics where applicable

Prepare new and review existing specifications, project plans, and other internal procedural documents. Ensure users and partners understand nature of work being performed, as well as timeframes and milestones. Provide regular status updates to supervisors and stakeholders

Provide support as needed for projecting annual receivable amounts, preparing projections related to pricing efforts, and predicting cost utilization as it relates to risk adjustment

Work with changing data, file specifications, and internally coordinate releases and modifications through approved procedures

Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes

Work with internal teams, provider partners, and vendor partners as needed to support risk adjustment activities

Provide mentorship, leadership, and training to less experienced risk adjustment analysts

Meet department and company performance and attendance expectations

Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues

Perform other duties as assigned

Qualification

Risk adjustment experienceData analyticsSAS/SQLHEDIS experienceMicrosoft ExcelCMS guidelines knowledgeProject leadershipCommunication skillsProblem solvingTeamwork

Required

Five years' experience in data analytics or software development required

At least three years' experience in Health Plan required

In depth risk adjustment and/or HEDIS ® experience required

Experience with risk models, CMS guidelines, regulatory data submissions, retrospective and prospective programs, interpreting health care regulatory/accreditation requirements and data validation audits required

Expertise in Microsoft Excel and SAS/SQL required

Experience in leading projects and project teams required

Familiarity with Medicaid risk adjustment and CMS 5-Star required

Bachelor's degree in Mathematics, Statistics, Health Informatics or similar research related field required

Expert-level analytical and problem-solving abilities are required

Mastery of theories and applications of computer programming required

Ability to keep current with changing technologies, work independently under limited supervision, exercise initiative within established procedural guidelines, and prioritize work to meet established deadlines a must

Excellent communication skills, both verbal and written, particularly the ability to convey technical information in an accessible and understandable manner

The ability to establish and maintain effective work relationships, exercise good judgement, and demonstrate decisiveness and creativity

Read, understand, and interpret documents of complex subject matter

Preferred

Familiarity with Risk Adjustment Documentation, Coding practices and NCQA quality metric experience preferred

Advanced degrees preferred

Company

PacificSource Health Plans

Founded in 1933, PacificSource is a not-for-profit health insurer for people and organizations throughout the Northwest.

Founded in 1933

Springfield, Oregon, USA

1001-5000 employees

http://www.pacificsource.com

H1B Sponsorship

PacificSource Health Plans has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

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Trends of Total Sponsorships

2025 (6)

2024 (4)

2023 (2)

2022 (4)

2021 (5)