Summary of JobLead the development of building a Risk Adjustment Data Modeling and Analytics tool for submissions to CMS-HCC, HHS-HCC, RX-HCC, CRG. Enhance efficiencies within the Risk Adjustment team through data optimization by targeting retrospective and prospective solutions through data modeling. Develop forecasting and efficiency models for contracted Risk Adjustment vendors. Lead the work and deliverables across multiple, complex projects from the planning stage to implementation, that impact multiple processes to optimize functions within the Risk Adjustment department. Align and drive strategic Risk Adjustment cost containment initiatives and goals. Partner with managers, vendors, executive leaders across the enterprise to ensure all workflow processes from Risk Adjustment to their interdependencies are identified and addressed.
Responsibilities- Responsible for building and maintaining internal CMS-HCC, HHS-HCC models, their output and analytics for our MA and ACA plans.
- Partner with leadership on the development of analytics that forecast vendor spend, premium revenue and efficiency of internal Risk Adjustment programs (collaborations with shared risk\shared savings provider organizations (i.e ACPNY, HCP, and other provider groups) as well as external partners.
- Deliver Risk Adjustment modelling outputs that lead the strategic deployment of our vendors as well as reporting on their efficacy by shared risk\shared savings partners.
- Partner with External Vendors (i.e Solventum) to gain market insights for NYS Medicaid and Essential Plan and develop models to track.
- Partner with the Actuarial Department on model validation and revenue forecasting for all lines of business.
- Track progress and communicate project status on a regular basis to all impacted parties.
- Work with project owners to develop, align, and refine program management oversight to maximize chances for successful delivery of projects.
- Responsible for communicating progress to Enterprise Risk Adjustment leadership and producing status reports presented to the broader Emblem Leadership across Finance, Product, and Provider Network.
- Responsible for capturing follow-ups and takeaways from these meetings.
Qualifications- Bachelor's Degree.
- Master's Degree in Health or Business Administration (Preferred)
- 5 - 8+ years of related, professional work experience (Required)
- Experience working with Government Sponsored Health Plans (Required)
- Experience working for a vendor or consultant working with Risk Adjustment Modeling, Bid Submissions (Required)
- Experience in a managed care environment or similar highly regulated industry (Preferred)
- Ability to understand and interpret information and to communicate ideas and information to all audiences (Required)
- Proficiency with Data Programming - SQL, Python, SAS (Required)
- Proficiency with Microsoft Suite - Word, Excel, PowerPoint, Outlook, Teams (Required)
- Detail oriented; ability to think independently and to identify and resolve issues and impediments to project success (Required)
- Excellent communication skills - verbal, written, interpersonal, negotiation; ability to build rapport and relationships (Required)
