Sr. Manager, Medical Risk Adjustment Analytics

CareSource

16h•Onsite

About The Position

The Senior Manager, Medical Risk Adjustment Analytics is responsible for the day to day operations of the risk adjustment function across all lines of business for the organization related to identification of member level risk opportunity, assignment of member level intervention approaches, risk adjustment data analytics and tracking ROI performance at an intervention level.

Requirements

Bachelor of Science degree in Finance, Business Administration, or Clinical related field or equivalent work experience is required
Seven (7) years of experience in analyzing health care claims data and/or risk scores, to include database experience (SAS, SQL, or Access), required
Three (3) years of management/supervisory experience required
Expert proficiency level with Microsoft Excel
Knowledgeable of Medicare/CMS Risk Adjustment regulations
Knowledgeable of ICD-10 and CPT codes
Ability to manage, develop, motivate and reward professional staff
Ability to effectively report data, analyze facts, and exercise sound business judgment when making recommendations
Critical listening and thinking skills
Advanced proficiency with Microsoft Suite to include, Word, Power Point and Outlook
Ability to work independently and to manage multiple priorities with limited resources
Ability to analyze problems, draw conclusions, develop processes and communicate status and results
Excellent oral and written communication skills
Ability to interact with executive levels of management as well as external stakeholders

Nice To Haves

Experience in communicating and presenting to senior leadership preferred
Knowledge of health care reporting standards preferred
Managed care or healthcare experience is preferred

Responsibilities

Analyzes member information to ensure the Risk Adjustment Factor accurately reflects the membership health profile
Develops and implements processes and procedures to ensure the accuracy and completeness of the Medicare Risk Adjustment, Medicaid and ACA/Marketplace data, and to ensure compliance with all CMS and State regulations and guidelines
Develops and maintains documentation of the Medicare Risk, ACA/Marketplace and Medicaid Adjustment processes
Analyzes and monitors clinical Risk Adjustment reports to and from CMS to assure data accuracy and compliance
Supports the development of monthly revenue accruals and forecast related to the risk adjustment activities
Maintain excellent understanding of all CMS and state requirements and directives for Risk Adjustment to ensure process is compliant with these requirements
Oversees and monitors data submission for attestation to CMS for Risk Adjustment
Oversees vendor and internal processes for accurate and timely Risk Adjustment Factor calculations across Medicare, ACA/Marketplace and Medicaid lines of business
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions
Perform any other job duties as requested