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. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to.
Senior Risk Adjustment Analyst
Location
United States
Posted
10 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. The Senior RA Analyst will collaborate and coordinate with internal and external partners to minimize submission and response errors, provide thorough oversight of vendor partners, accumulate, and report out on pertinent data sets, develop and improve processes related to risk adjustment and quality improvement, maintain required documentation, and ensure compliance to all applicable laws, guidance, and regulations. Assume lead role on specified projects. Projects are completed with cross-functional teams of peers and business partners. This includes interaction with provider partners with the intent of informing them on performance and educating on best practices in risk adjustment. The Senior RA Analyst will provide mentorship to less experienced team members. In addition, this position influences decision making by leadership and provides 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 - 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, 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. - Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings. - 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. - 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. - Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes. - Provide mentorship, leadership, and training to less experienced risk adjustment analysts. Benefits - Base Range: $74,601.93 - $126,822.77 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. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
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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 !!!
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