Senior Data Analyst - ACA Risk Adjustment (Hybrid)

CareFirst•Baltimore, MD

1d•Hybrid

About The Position

The purpose of a Sr. Data Analyst is to support ACA risk adjustment processes, including EDGE server analysis and submission validation. Ensure accuracy and integrity of risk adjustment performance metrics through proactive analysis and validation of data sources including claims, enrollment, provider, and EDGE submissions. Analyze and interpret CMS and HHS risk adjustment methodologies to support risk score calculation and financial performance insights.

Requirements

Bachelor's Degree in Data Science, Mathematics, Computer Science, Statistics, Business or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
5 years' experience in an analytical/quantitative role.
Quantitative, analytical and problem-solving skills.
Knowledge and understanding of analytical tools, languages, applications, platforms.
Excellent communication skills both written and verbal.
Ability to learn quickly and take direction.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship

Nice To Haves

Experience in Healthcare Industry.
Hands on experience with Big Data/NoSQL Platforms with experience delivering production projects at scale.
Experience with SAS, SQL, Python or other programming language.
Experience with ACA HHS risk score methodology, including risk score calculation and financial risk receivable calculations.
Experience with EDGE Submission Error Analyses and reporting.

Responsibilities

Engages in data exploration using various programming languages (reading and writing code), requiring advanced knowledge of multiple database structures.
Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDGE processes and key regulatory deadlines for data submission.
Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue.
Collect, analyze, and interpret data to glean insights, and develop business appropriate recommendations.
Assists in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance.
Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in maximizing reimbursement based on the CMS-HCC (Hierarchical Condition Code) model.
Perform data mining of claims and data to identify trends, data issues and members with missing HCCs.
Research and analyze data flow across complex data ecosystem including operational and analytical data platforms.
Serve as an expert resource supporting data questions and issues from stakeholders and driving to resolution.
Collaborate across business units to coordinate the development of financial dashboards and models to identify and track revenue and ROI trends.
Work with team members to understand and monitor the financial impact of risk adjustment programs.
Contribute to developing materials and presenting key updates to leadership regarding risk adjustment programs and provider and member engagement initiatives.
Lead in the design, development, validation and delivery of data to provide insight into business decisions.
Conduct analyses to develop a comprehensive understanding of a providers risk score trends, EMR systems and contracting arrangements to recommend and generate provider-specific engagement plans.
Oversee the analysis and interpretation of provider-specific results and risk score trend information.
Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy and identification of member health conditions.
Update, create and maintain business process and technical workflow documents.
Manage the collection of business and technical requirements from Stakeholders to deliver data driven solutions.
Produces technical documentation that is consistent with professional standards.
Be a resource and mentor to junior level staff.