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.
-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 junior analysts. Actively participate in the peer review process by reviewing, providing insight, and verifying the 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).
Education/Experience - 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), using various databases and other data sources, and performing analytics.
Additional Licensing, Certifications, Registrations - SAS, Oracle, or SQL certification a plus
Knowledge - 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 databases 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
Travel (If Applicable)Salary Range:
$108, 000 - $115, 605
