Risk Adjustment Analyst

The Risk Adjustment Analyst is responsible for supporting the Medicare Advantage and Commercial Risk Adjustment programs through the end-to-end processes of data management and data submissions. This will be accomplished through designing, building and automating reporting analysis and modeling by utilizing a variety of systems. The position helps to create visibility of the risk adjustment initiatives by measuring project success, KPI development and goal tracking. Along with providing analytical support for the risk adjustment initiatives, the analyst will assist in developing and implementing systems, processes and standards to ensure the risk scores appropriately reflect the disease burden of each member.

This position develops and coordinates the risk adjustment improvement and reporting efforts, for Hometown Healths Medicare and Commercial products utilizing a variety of source systems and development tools. Included within the scope of this position, the analyst will perform data extraction, analysis, report design, report build, solution deployment, and draft documentation to support the Financial and Business reporting solutions for Hometown Health. Accurate and timely project status feedback is expected to ensure compliance with established timelines.

KNOWLEDGE, SKILLS & ABILITIES:

1. Perform analysis and reporting activities relating to: risk score calculation, claims/encounters data submission, chart review programs, audits, and related performance metrics.

2. Participate in the development of requirements, testing and refinement of the underlying data and systems.

3. Collaborate with other business units to deliver reports/updates on underlying data and systems as used by the Risk Adjustment team.

4. Analyze data flow and data integrity to identify areas for improvement.

5. Understand and advise on CMS risk score methodology, including risk score calculation, hierarchical condition categories (HCCs), financial risk receivable calculations, RAPS and EDS processes and key regulator deadlines for data submission, RAPS and EDS Return Files and Error Files, ICD coding, claims, and provider data.

6. Operate risk adjustment analytic vendor platforms to assist with intervention tracking, monitoring, analysis and reporting of diagnosis codes that drive risk score calculations.

7. Work cross functionally across multiple departments to design and develop financial dashboards, KPIs, and models to identify and track profit/loss and ROI trends.

8. Collaborate with Risk Adjustment Coders and Risk Adjustment Nurses to build internal projects based on diagnosis code, procedures, etc. trends for prospective and/or retrospective review.

9. Contribute to developing materials and presenting key updates to Senior Leadership regarding risk adjustment programs and provider and member engagement initiatives.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Bachelors degree from an accredited institution required.

Preferred concentration in Business, Finance, Economics, Computer Science or Management Information Systems.

Experience:

1. Minimum of two years in an analyst role required, preferably in the healthcare industry.

2. Advanced Excel skills required, that include working with large data sets, creating standardized reports, utilizing vLookups and advanced functions/ formulas; creating, using and interpreting pivot tables, filtering and formatting.

3. Preferred work experience with SAS and/or SQL to create queries, pull large data sets and perform data manipulations/analysis

4. Preferred experience with ICD codes, medical claims, Medicare Advantage and Commercial/ACA products.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.