Note: The job is a remote job and is open to candidates in USA. PacificSource Health Plans is dedicated to helping members access quality, affordable care. The Senior Risk Adjustment Analyst plays a crucial role in ensuring accurate data submission to regulatory entities and collaborates with various partners to enhance risk adjustment processes and outcomes.
Responsibilities
- Recommend and guide process improvements that will optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden
- Identify, analyze, interpret and communicate risk adjustment trends to be consumed by provider partners and related entities
- Responsible for maintenance of existing reports, development of new reports to help ensure company goals are met, as well as other ad hoc requests as needed
- Develop and maintain reporting capabilities to measure and forecast risk scores & quality metrics, monitor suspecting model performance, and identify areas of improvement
- Maximize risk adjustment revenue and quality bonus payments by driving data integration and analytics to properly capture and improve the health status of PacificSource members
- Validate data integrity and collaborate with technical teams to improve data pipelines and business logic for identified areas of opportunity
- Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment and quality data submission
- Develop and maintain data sets leveraging internal data, response data from regulatory entities (including but not limited to: EDGE files, MMR, MOR, RAPS Response, MAO-004, PSV, PLD, 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
- Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy
- Assist with all pertinent audits, including RADV, through preparation activities and documentation. Perform root cause analysis to maintain high integrity data and processes to minimize discrepancies and gaps
- Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings. This includes review of regulatory announcements, attending educational sessions and opportunities provided by regulatory entities or within the industry
- Develop, maintain, and report out on actionable metrics related to risk adjustment and HEDIS ® to incorporate quality/health outcome metrics where applicable
- Prepare new and review existing specifications, project plans, and other internal procedural documents. Ensure users and partners understand nature of work being performed, as well as timeframes and milestones. Provide regular status updates to supervisors and stakeholders
- 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
- Work with changing data, file specifications, and internally coordinate releases and modifications through approved procedures
- Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes
- Work with internal teams, provider partners, and vendor partners as needed to support risk adjustment activities
- Provide mentorship, leadership, and training to less experienced risk adjustment analysts
- 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
- Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues
- Perform other duties as assigned
Skills
- Five years' experience in data analytics or software development required
- At least three years' experience in Health Plan required
- In depth risk adjustment and/or HEDIS ® experience required
- Experience with risk models, CMS guidelines, regulatory data submissions, retrospective and prospective programs, interpreting health care regulatory/accreditation requirements and data validation audits
- Expertise in Microsoft Excel and SAS/SQL is required
- Experience in leading projects and project teams required
- Familiarity with Medicaid risk adjustment and CMS 5-Star required
- Bachelor's degree in Mathematics, Statistics, Health Informatics or similar research related field required
- Expert-level analytical and problem-solving abilities are required
- Mastery of theories and applications of computer programming required
- 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
- Excellent communication skills, both verbal and written, particularly the ability to convey technical information in an accessible and understandable manner
- 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
- Familiarity with Risk Adjustment Documentation, Coding practices and NCQA quality metric experience preferred
- Advanced degrees preferred
Company Overview