SCOPE OF ROLE

The Bright Health Risk Adjustment and Coding Team is an integral component of Bright’s success as it defines and ensures outstanding clinical care for our members. The Risk Adjustment Encounters Team is responsible for all submissions and encounters business functions. The Risk Adjustment Encounters Business Analyst role looks end-to-end from enrollment staging, claims acquisition, clearing house, data lake, provision for vendor transfer, and finally to CMS response file reconciliation. This role works across departments, teams, and vendors to deliver a best in class submission accuracy across all lines of business.

ROLE RESPONSIBILITIES

The Risk Adjustment Business Analyst job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Contributes to encounters readiness by ensuring proper setup of new products
• Participates vendor partnership, and data transfer
• Finds, communicates, and escalates root causes and ad hoc nuances
• Prioritizes work to meet encounter related metrics and provides status for leadership teams on a cyclical basis
• Assists with and tracks risk adjustment related initiatives and strategies
• Seeks, maintains, and builds a best a class encounters knowledge-base
• Relentlessly champions the importance of successful encounters through the lens of payer value
• Contributes content for policies, procedures, and program guides
• Follows, reports, and adheres to all regulatory guidance
• Other duties and responsibilities as assigned
• Proficiency in SQL, SAS, and or other data aggregation platforms a plus

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor's Degree required, ideally in a healthcare or technical related field
• One (1) or more years’ experience in Medicare Advantage, Commercial, and related encounters submission, health care, and risk adjustment required
• Three (3) or more years’ experience managing and reporting on progress of department initiatives required
• Knowledge of Medicare Advantage, Commercial, and related encounters or claims lifecycle
• Proven ability to communicate Medicare Advantage, Commercial, and related encounters or claims accuracy and reconciliation
• Extensive knowledge of risk adjustment models and strategies, preferred
• Proficient in Microsoft Office Products; Word, Excel, PowerPoint, advanced proficiency preferred

PROFESSIONAL COMPETENCIES

• Strong written and verbal communication skills
• Strong attention to detail
• Ability to quickly learn and adapt to meet business needs
• Experience working with Risk Adjustment vendors
• Demonstrated knowledge of risk adjustment regulations
• Ability to work independently
• Ability to build relationships with office staff, physicians, and market team

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
• Travel may be required.