CareFirst BlueCross BlueShield
Senior Risk Adjustment Analyst- ACA Encounters (Hybrid)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
Overview
Senior ACA Encounters Risk Adjustment Analyst (Hybrid) role at CareFirst BlueCross BlueShield. The incumbent assumes a proactive approach in ensuring the accuracy and integrity of risk adjustment performance metrics through coordination of analytical processes, investigation and interpretation of HHS risk score methodology, risk score calculation, enrollment, submissions, premiums, medical and pharmacy claims, and provider data. Responsible for performing complex analyses and problem resolution including data integrity extraction, report design, report build and solution deployment. Includes establishing and maintaining business process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company and external entities, and providing coordination and support as required.
Essential Functions
Accurately monitor and reconcile submitted encounters against EDGE and response files to address submission gaps, collaborate with departments to improve data quality, and develop dashboard reporting with regular delivery of results to improve awareness of risk adjustment results and quality. Update, create and maintain business process and technical workflow documents.
Understand CMS risk score methodology, risk score calculation, financial risk receivable calculations, EDPS processes, and key regulatory data submission deadlines. Assess the impact of HCCs on risk adjustment revenue and support actuarial in calculating risk adjustment revenue.
Assist in designing an analytic suite and actionable reports to solve problems, provide data-driven guidance, monitor risk adjustment performance, and identify opportunities in accurate reimbursement based on the HHS-HCC model. Perform data mining to identify trends, data issues and members with missing HCCs.
Support project management efforts including monitoring progress against timelines and milestones, developing tracking mechanisms for Risk Adjustment and Coding programs, and aiding management to define and achieve key performance metrics.
Collaborate across business units to develop financial dashboards and models to identify revenue and ROI trends. Help prepare materials and present updates to leadership on risk adjustment programs and provider/member engagement initiatives.
Supervisory Responsibility Position does not have direct reports but may assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
Qualifications Education Level:
Bachelor’s Degree, or in lieu of a Bachelor's degree, an additional 4 years of relevant work experience in addition to the required work experience.
Experience:
5 years of experience with data analysis including the use of statistical methods and programming languages.
Knowledge, Skills And Abilities (KSAs)
Experience with SAS, SQL, VBA or other programming language and MS Access.
Experience with EDPS & MA or Medicaid risk score methodology, including risk score calculation and financial risk receivable calculations.
Excellent analytical and problem-solving abilities.
High level statistical abilities and ability to work independently and with cross-functional teams.
Ability to work with Senior Management and summarize information for high-level decision-making.
Salary Salary Range: $64,080 - $127,270
Salary Range Disclaimer:
The disclosed range is not adjusted for geographic differential and reflects factors such as scope and responsibilities, candidate experience, education, internal equity, and market considerations.
Department Risk Adjustment
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply Please visit our website to apply: www.carefirst.com/careers
Location Laurel, MD
#J-18808-Ljbffr
Senior ACA Encounters Risk Adjustment Analyst (Hybrid) role at CareFirst BlueCross BlueShield. The incumbent assumes a proactive approach in ensuring the accuracy and integrity of risk adjustment performance metrics through coordination of analytical processes, investigation and interpretation of HHS risk score methodology, risk score calculation, enrollment, submissions, premiums, medical and pharmacy claims, and provider data. Responsible for performing complex analyses and problem resolution including data integrity extraction, report design, report build and solution deployment. Includes establishing and maintaining business process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company and external entities, and providing coordination and support as required.
Essential Functions
Accurately monitor and reconcile submitted encounters against EDGE and response files to address submission gaps, collaborate with departments to improve data quality, and develop dashboard reporting with regular delivery of results to improve awareness of risk adjustment results and quality. Update, create and maintain business process and technical workflow documents.
Understand CMS risk score methodology, risk score calculation, financial risk receivable calculations, EDPS processes, and key regulatory data submission deadlines. Assess the impact of HCCs on risk adjustment revenue and support actuarial in calculating risk adjustment revenue.
Assist in designing an analytic suite and actionable reports to solve problems, provide data-driven guidance, monitor risk adjustment performance, and identify opportunities in accurate reimbursement based on the HHS-HCC model. Perform data mining to identify trends, data issues and members with missing HCCs.
Support project management efforts including monitoring progress against timelines and milestones, developing tracking mechanisms for Risk Adjustment and Coding programs, and aiding management to define and achieve key performance metrics.
Collaborate across business units to develop financial dashboards and models to identify revenue and ROI trends. Help prepare materials and present updates to leadership on risk adjustment programs and provider/member engagement initiatives.
Supervisory Responsibility Position does not have direct reports but may assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
Qualifications Education Level:
Bachelor’s Degree, or in lieu of a Bachelor's degree, an additional 4 years of relevant work experience in addition to the required work experience.
Experience:
5 years of experience with data analysis including the use of statistical methods and programming languages.
Knowledge, Skills And Abilities (KSAs)
Experience with SAS, SQL, VBA or other programming language and MS Access.
Experience with EDPS & MA or Medicaid risk score methodology, including risk score calculation and financial risk receivable calculations.
Excellent analytical and problem-solving abilities.
High level statistical abilities and ability to work independently and with cross-functional teams.
Ability to work with Senior Management and summarize information for high-level decision-making.
Salary Salary Range: $64,080 - $127,270
Salary Range Disclaimer:
The disclosed range is not adjusted for geographic differential and reflects factors such as scope and responsibilities, candidate experience, education, internal equity, and market considerations.
Department Risk Adjustment
Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply Please visit our website to apply: www.carefirst.com/careers
Location Laurel, MD
#J-18808-Ljbffr