Risk Adjustment Analytic Manager

PacificSource Health Plans • Bend, OR

1d • $108,715 - $190,252

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. The Risk Adjustment Analytic Manager reports to the Director of Risk Assessment and will oversee technical aspects of Risk Adjustment operations including data staging and submission oversight, reporting and analytics, retrospective and prospective program support, vendor oversight, and RADV mitigation strategies. The Risk Adjustment Manager will lead a team of Risk Adjustment Analysts to accomplish these tasks and execute on strategy laid out by the Director and Senior Leadership. The Manager will collaborate with internal teams such as Quality, Population Health, Actuarial, Analytics, IT, Finance, Provider Network, and others. The Manager will interact with external vendor partners to manage data flow, report sharing, and address general oversight concerns. In addition, the Manager will interact with regulatory entities such as CMS to stay updated on changes that would affect operations within the company as well as ensure fulfillment of deadline requirements. Responsibilities include the above activities across the Medicare Advantage, Commercial ACA, and Medicaid member populations. The Manager will ensure compliance to all applicable laws, guidance, and regulations.

Requirements

• Five years of experience in data analytics required, to include at least 2 years risk adjustment experience with a Health Plan.
• In depth Medicare and Commercial ACA risk adjustment experience required, including risk model and CMS guidelines, RAPS/EDS & EDGE data submissions, retrospective and prospective programs, and RADV audits.
• Expertise in Microsoft Excel and SAS/SQL is required.
• Experience in leading projects and project teams required.
• Excellent analytical and problem solving abilities are required.
• Mastery of theories and applications of computer programming required (SAS and VBA are the primary tools used).
• 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.
• Ability to communicate clearly and concisely, both orally and in writing when making presentations and creating documents.
• 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.
• Accountable leadership
• Collaboration
• Data-driven & Analytical
• Delegation
• Effective communication
• Listening (active)
• Situational Leadership
• Strategic Thinking
• Stoop and bend.
• Sit and/or stand for extended periods of time while performing core job functions.
• Repetitive motions to include typing, sorting and filing.
• Light lifting and carrying of files and business materials.
• Ability to read and comprehend both written and spoken English.
• Communicate clearly and effectively.
• Bachelor's degree in Mathematics, Statistics, or similar research related field required.

Nice To Haves

• Familiarity with Medicaid risk adjustment preferred.
• Familiarity with Risk Adjustment Documentation and Coding practices preferred.
• Medicare Stars and/or HEDIS experience preferred.
• Equivalent work and education experience will be considered.
• Advanced degrees preferred.

Responsibilities

• Execute the operational aspects of the strategic direction and plan for risk adjustment including performance metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives
• Develop analytic processes to help ensure accuracy and comprehensiveness of HCC reporting to CMS and assist in Risk Adjustment programs to ensure that risk exposures and opportunities are identified timely and appropriately, with a goal to optimize the program.
• Support of the Medicare Advantage Encounter Data Processing System, Risk Adjustment and Payment System (as applicable), Commercial Risk Adjustment EDGE Server, and Medicaid Encounter System from a Risk Adjustment perspective and ensure optimal submission.
• Monitor and analyze risk score trends.
• Work with IT and Actuarial staff to reconcile data with financials, forecast risk adjustment factors, and model impacts of potential payment changes.
• Assist with Risk Adjustment Data Validation (RADV) audits by government agencies or outside audit vendors, assisting internal stakeholders and supporting medical record reviews to validate diagnoses.
• Develop analytics and tools to mitigate risk associated with inaccurate coding and risk scores which could result in lost revenue, potential CMS sanctions or penalties, and disadvantages relative to competitors.
• Develop, maintain, and report out on actionable metrics related to risk adjustment and incorporate quality/health outcome metrics where applicable.
• 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.
• Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment data submission.
• Develop and maintain data sets leveraging internal data, response data from regulatory entities (EDGE files, MMR, MOR, RAPS Response, MAO-004, 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.
• Assist in the management of vendor contracts/relationships and look for effective ways to optimize vendor services using data driven strategies.
• Performs employee management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Interact with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial, and Compliance.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Strong analytical/financial skills.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Actively participate as a key team member in manager/supervisor meetings.
• Assists in annual Medicare Bid process.
• 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.
• Perform other duties as assigned.

Benefits

• Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level