ACA/Medicare Risk Adjustment Analyst Sr.

Baylor Scott & White Health

97d

About The Position

The Risk Adjustment Analyst Sr is responsible for monitoring and oversight of the end-to-end encounter management workflow. This position analyzes complex encounter inbound/outbound process issues, using data from internal and external sources to provide insight to decision-makers. This role supports program management activities around risk adjustment data management and submissions to CMS. This role may require some domestic travel to support network partnerships and new strategic implementations.

Requirements

• Bachelor's in Quantitative discipline such as finance, economics, or mathematics or 4 years of work experience above the minimum qualification.
• 2 Years of Experience in Healthcare Analytics.
• 2 years working with ACA and Medical Claims, MMR, MOR, MAO-002, MAO-004 and RAPs/EDS data.
• Experience with Healthcare claims, enrollment and pharmacy data is preferred.
• Knowledge of ACA, Medicare, and TPA business requirements is a plus.

Nice To Haves

• Advanced knowledge of SQL, MS Excel, MS Access, MS Word, MS Visio and MS PowerPoint.
• Experience with healthcare encounters, enrollment and pharmacy data preferred.

Responsibilities

• Responsible for documenting, monitoring, and analyzing the end-to-end encounter life cycle, inbound and outbound encounter process.
• Monitors and oversees the end-to-end claims encounter management workflow.
• Identifies and interprets encounter data, submission requirements and performance metrics per the regulatory and health plan guidelines.
• Performs analysis and reporting activities related to risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics.
• Analyzes claims and supplemental data to identify reporting gaps, risk gaps and/or sources of incorrect and incomplete diagnostic data.
• Using data from internal and external sources, analyzes complex encounter inbound/outbound process issues to provide insight to decision-makers.
• Researches and documents all encounter errors in established systems(s)/database(s) with appropriate statistical trend analysis.
• Performs root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry standards.
• Collaborates across various departments to design and implement any business process and/or systems changes to meet encounter data processing and submission goals.
• Communicates regularly with management on issues discovered through research efforts.
• Develops various encounter related reports (i.e., exception reports, performance reports, root cause analysis outcome reports, etc.) and distributes them to appropriate departments for error resolution, follow up and performance monitoring.
• Participates in the workgroup to resolve encounter data and process issues.
• Analysis and forecasting of risk adjusted revenue PMPM by contact, plan and member cohorts.
• Perform analysis and reporting activities relating to risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics.
• Performs various financial analysis such as revenue forecasting and ROI.
• Contributes to program improvement by designing and implementing business process and system changes, collaborating to resolve encounter data and process issues and managing policy and procedure documentation.
• Oversee updates to department policies and procedures regarding risk adjustment data management.
• Remain current on CMS Risk Adjustment models and data collection requirements.

Benefits

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees