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Senior Risk Adjustment Analyst
Location
United States
Posted
9 days ago
Salary
$74.6K - $126.8K / year
Seniority
Senior
No structured requirement data.
Job Description
Senior Risk Adjustment Analyst
PacificSource Health Plans
Role Description The Senior Risk Adjustment (RA) Analyst assists in the accurate and comprehensive data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable populations. This position leverages available tools and knowledge of the applicable risk models to optimize data submission as it pertains to Hierarchical Condition Categories (HCCs), HEDIS® and Quality performance as well as other data within a given system. - Collaborate and coordinate with internal and external partners to minimize submission and response errors. - Provide thorough oversight of vendor partners and accumulate, report out on pertinent data sets. - Develop and improve processes related to risk adjustment and quality improvement. - Maintain required documentation and ensure compliance with all applicable laws, guidance, and regulations. - Assume lead role on specified projects completed with cross-functional teams. - Interact with provider partners to inform them on performance and educate on best practices in risk adjustment. - Provide mentorship to less experienced team members. - Influence decision making by leadership and provide recommendations regarding potential improvements to risk adjustment processes and outcomes. Qualifications - 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. - 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. - Familiarity with Risk Adjustment Documentation, Coding practices and NCQA quality metric experience preferred. - Equivalent work and education experience will be considered. Requirements - Bachelor's degree in Mathematics, Statistics, Health Informatics or similar research related field required. - Advanced degrees preferred. - 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 and work independently. - Excellent communication skills, both verbal and written. - Ability to establish and maintain effective work relationships. - Read, understand, and interpret documents of complex subject matter. Benefits - Compensation range: $74,601.93 - $126,822.77. - Actual compensation will be determined based on qualifications, experience, education, and internal equity. Company Description PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. - Values the diversity of our community, including those we hire and serve. - Committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected, and responded to.
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Role Description This role is completely remote! Please Note: - Candidates based in the New York/New Jersey area or within the Eastern or Central time zone will be given preference over candidates from other locations. Job Details: - Requires detail-oriented person to assist clients to complete various quarterly/annual state reporting requirements to maintain Workers' Compensation Qualified Self-Insurance status and/or compliance with monopolistic fund requirements. - The ideal candidate will have related prior experience in multiple states. - Job duties as follows: - Maintain and closely adhere to schedule of reporting requirements for each client by entity and by state. - Request and obtain payroll, class codes, hours, loss information, financial statements and other documents from the client, TPA or other as required in each state. - Follow up with client or others on tight diary for receipt of information in order to stay in compliance with strict state deadlines. - Actively review status of all activity and input information into the various state web portals. - Guide clients on certifying and/or signing off on information on the web portals. Instruct clients on payment requirements. - Maintain detailed records of all activity including requests for documents, data, actuarial reports, proof of payments, etc. - Assist clients to add entities to state programs as necessary. - Review surety bonds or other security requirements and levels with each state. Request review of security as necessary. - Provide actuarial reports and other information requested by the state to support security. Qualifications - The ideal candidate will have experience conducting annual/quarterly filings in multiple states within an employer risk management/HR/payroll department, broker, consulting firm or on the receiving end of filings within a state department of insurance/labor.
Insurance Risk Interviewer I
Quest DiagnosticsA Fortune 500 company cited on the S&P 500 Index, Quest Diagnostics is a healthcare products and services provider offering diagnostic testing to 1-in-3 U.S. ad
Role Description The primary purpose of this position is to complete life insurance medical and financial interviews via telephone through outbound calls for multiple client companies. Schedule: Monday to Friday, 8:00AM – 4:30PM Central, with rotational weekends. Pay range: $17/hour. Salary offers are based on a wide range of factors including relevant skills, training, experience, education, and, where applicable, certifications obtained. Market and organizational factors are also considered. Successful candidates may be eligible to receive annual performance bonus compensation. Qualifications - Relevant skills and training - Experience in life insurance or related fields - Education background related to the role - Certifications obtained (if applicable) Requirements - Ability to conduct interviews via telephone - Strong communication skills - Ability to work Monday to Friday, 8:00AM – 4:30PM Central - Willingness to work rotational weekends Benefits - Day 1 Medical, supplemental health, dental & vision for FT employees who work 30+ hours - Best-in-class well-being programs - Annual, no-cost health assessment program Blueprint for Wellness® - healthyMINDS mental health program - Vacation and Health/Flex Time - 6 Holidays plus 1 "MyDay" off - FinFit financial coaching and services - 401(k) pre-tax and/or Roth IRA with company match up to 5% after 12 months of service - Employee stock purchase plan - Life and disability insurance, plus buy-up option - Flexible Spending Accounts - Annual incentive plans - Matching gifts program - Education assistance through MyQuest for Education - Career advancement opportunities - And so much more!
Arquitecto de Procesos – Riesgo de Mercado
KeppriEspecialistas en el end to end de activos digitales, staffing y Servicios Tecnológicos. Hazlo fácil con KEPPRI !!!
• Construir el entendimiento y la visión del negocio a partir de journeys, modelos de indicadores y lineamientos estratégicos, dejando explícito el modelo de negocio de la arquitectura (portafolio de servicios y estructura). • Definir el mapa de capacidades del negocio y su inventario, estableciendo qué debe saber hacer el área para cumplir su estrategia. • Levantar la arquitectura AS IS: mapear procesos y componentes, asociar aplicaciones e inventarios de sistemas, e identificar tableros e indicadores de operación y experiencia. • Diseñar la arquitectura TO BE y el modelo operativo objetivo a alto nivel: priorización estratégica de capacidades, arquetipos de procesos e identificación de componentes. • Producir el análisis de brechas (mapa de gaps), priorizar iniciativas y consolidar el roadmap de transformación. • Asegurar trazabilidad y consistencia entre capas (negocio, procesos, aplicaciones, datos) y alinear los entregables con estándares de arquitectura empresarial. • Facilitar talleres con stakeholders de negocio, riesgo y tecnología, y comunicar la arquitectura a niveles ejecutivos y técnicos.
Arquitecto de Procesos – Riesgo de Mercado
KeppriEspecialistas en el end to end de activos digitales, staffing y Servicios Tecnológicos. Hazlo fácil con KEPPRI !!!
• Construir el entendimiento y la visión del negocio a partir de journeys, modelos de indicadores y lineamientos estratégicos, dejando explícito el modelo de negocio de la arquitectura (portafolio de servicios y estructura). • Definir el mapa de capacidades del negocio y su inventario, estableciendo qué debe saber hacer el área para cumplir su estrategia. • Levantar la arquitectura AS IS: mapear procesos y componentes, asociar aplicaciones e inventarios de sistemas, e identificar tableros e indicadores de operación y experiencia. • Diseñar la arquitectura TO BE y el modelo operativo objetivo a alto nivel: priorización estratégica de capacidades, arquetipos de procesos e identificación de componentes. • Producir el análisis de brechas (mapa de gaps), priorizar iniciativas y consolidar el roadmap de transformación. • Asegurar trazabilidad y consistencia entre capas (negocio, procesos, aplicaciones, datos) y alinear los entregables con estándares de arquitectura empresarial. • Facilitar talleres con stakeholders de negocio, riesgo y tecnología, y comunicar la arquitectura a niveles ejecutivos y técnicos.


