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Horizon Blue Cross Blue Shield of New Jersey logo
Horizon Blue Cross Blue Shield of New Jersey

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive.

Risk Adjustment Data Analyst III

Data AnalystData AnalystFull TimeRemoteMid LevelTeam 4,974Since 1932Company Site

Location

United States

Posted

36 days ago

Salary

$87.3K - $119.1K / year

Seniority

Mid Level

Job Description

Risk Adjustment Data Analyst III

Horizon Blue Cross Blue Shield of New Jersey

Role Description The Risk Adjustment Data Analyst III is a seasoned analyst responsible for playing an active role in submission, monitoring and contributing to the end to end Risk Adjustment Data Submission and Validation within key regulator guidelines for acceptable data submission. The analyst will also be responsible for oversight and participation in the timely completion of projects, including timeline development & maintenance as it pertains to encounter and risk adjustment data. What You'll Do - Collaborate with internal and external stakeholders involved in Risk Adjustment data submission, as well as all other mandatory aspects of Risk Adjustment. - Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines. - Research and document encounter errors in established systems and databases with appropriate statistical trend analysis, perform root cause analysis of encounters processing and submission issues and develop recommendations based on data and industry standards. - Contribute to the creation of technical documents and high level solution designs. - Participate in the development, testing and implementation of system specifications. - Interact with RA leadership to create predictive models using information obtained from data mining or analysis. - Assist in onboarding and coaching of junior analysts. Actively participate in the peer review process by reviewing, providing insight, and verifying work of junior analysts. - Conduct gap analysis, data collection and validation related to Risk Adjustment activities. - Contribute to program improvement by designing and implementing business process and system changes, collaborate to resolve encounter data and process issues and manage policy and procedure documentation. - Use data from internal and external sources, analyze complex encounter inbound/outbound process issues to provide insight to decision-makers. - Support and participate in internal and external audits as needed. - Produce recurring and ad-hoc reports for business stakeholders for risk adjustment optimization. - Remain informed and updated on industry changes e.g. CMS regulations and changes (EDPS, Risk Adjustment Payment Model Changes). Qualifications - Bachelor’s degree preferred from an accredited college or university preferably in Computer Science, Data Science or other strong analytical field. - Master’s degree a plus. - Requires a minimum of five (5) years of experience with programming or analytics, preferably in health care, insurance or related field; clinical and medical claims data and disease diagnostic coding practice a plus. - Experience with manipulating large amounts of clinical and medical claims data while working in health care industry, insurance or related field. - Requires experience using programming and statistical software (e.g., SAS), use of various databases and other data sources, and performing analytics. Requirements - SAS, Oracle, or SQL certification a plus. - Advanced knowledge in Excel (including pivot tables) and Access required. - Advanced knowledge of SAS, Oracle or SQL required. - Knowledge of R and Python is a plus. - Knowledge of risk adjustment programs for Medicare/Medicaid, or risk mitigation programs under ACA, is a plus. Skills and Abilities - Strong analytical, research and problem-solving skills; experience with relational database and techniques. - Strong attention to detail. - Written and oral communication skills. - Proficiency in Microsoft software applications. - Ability to perform and interpret a variety of data analyses. - Demonstrated ability to evaluate and interpret complex data. - Demonstrated ability to handle multiple tasks with competing priorities. Benefits - Comprehensive health benefits (Medical/Dental/Vision). - Retirement Plans. - Generous PTO. - Incentive Plans. - Wellness Programs. - Paid Volunteer Time Off. - Tuition Reimbursement.

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