SCOPE OF ROLE

The Risk Adjustment analyst is responsible for report creation to support Risk Adjustment initiatives to include Direct Contracting (DCE). This position will be expected to perform data and analytical services in support of optimizing provider performance leading to risk adjusted revenue, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies. Working understanding of various risk adjustment models. Works under general supervision of the AVP of Risk Adjustment and Analytics teams

ROLE RESPONSIBILITIES

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

• Collaborates regularly with internal departments, including Finance and Actuarial, Medicare Operations, Network Management, Provider Contracting, Provider Relations Health Economics, and external vendors on risk adjustment projects. Calculates ROI for risk adjustment vendor prospective programs initiatives and projects
• Develops regular and ad-hoc reports to support risk adjustment processes through query building and data extraction, including monthly reconciliation reporting
• Maintains current knowledge of CMS’ Hierarchical Condition Categories (HCC) CMMI-HCC, CRG Risk Adjustment Models
• Works on identifying gaps in the claims, encounter reconciliation process, and provides insights to educate providers to improve CDQI/coding practices
• Responsible for understanding HEDIS and STARS measure principles and partnering with the Quality team to drive improved provider performance related to Risk Adjustment/Quality

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• A Bachelor’s degree in Math, Statistics, Economics, or a related field is required.
• Five (5) or more years of experience working as a health care data analyst, with a minimum of Three (3) years with Medicare Advantage and/or ACA RA is required.
• Working understanding of how ACA and Med Adv risk adjustment works, the key drivers and most influential variables; working knowledge of DCE risk adjustment preferred.
• Understanding of healthcare claims data, provider data.

PROFESSIONAL COMPETENCIES

• Proficient in Microsoft Excel and other Office products.
• Experience with forecasting, modeling, using SQL or SAS, Crystal reports or Power-BI is preferred.
• Immediate level knowledge of risk adjustment /Quality measures for ACA and Med Adv required; DCE products knowledge preferred.
• Produce, understand, and interpret internal and external analyses and reports; provide effective technical and non-technical support to internal and external stakeholders. Strong communication and collaboration skills.

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.