- Perform analysis and reporting activities relating to: risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics.
- Analysis and reporting on RAF Forecast Model and risk adjusted revenue PMPM by plan/patient cohorts and review cost and utilization trends to understand impact on revenue; along with reconciliation and root cause analysis for any variance.
- Analysis and reporting of revenue results to assist financialreporting, forecasting and budget development.
- Design and develop dashboard for reporting related to Risk Adjustment and Senior Revenue Finance.
- Analysis and reporting on HCC program initiatives relative to benchmarks/targets.
- Analysis and reporting on CMS data like MMR and MOR received through various health plans.
- Develop tools and conduct analysis to evaluate accuracy and completeness of encounter exchange with capitated providers.
- Work with EDI team to ensure timely and accurate encounter submissions to health plans and other state or federal agencies. Analyze the financial impact of data issues and encounter rejection buckets.
- Communicate and collaborate with internal and external stakeholders on risk adjustment related analysis, knowledge or both.
- Comply with HIPAA Regulations and company compliance policy.
- Stay updated and share knowledge on industry changes especially any changes on CMS side (changes like ICD10, EDS, Payment Model Changes)
EDUCATIONBachelor’s degree from a four-year college required; preferred: major in information systems or related quantitative field (finance, computer science or, mathematics).
- 5 - 7 years of healthcare analytics experience.
- Strong understanding of Medicare Risk Adjustment Payment Model and Cycle including the knowledge base to calculate and manipulate risk scores.
- Experience with Risk Score and Revenue forecast is a plus.
- Deep familiarity with CMS data and risk adjustment processes including MMR, MOR and EDS data.
- Strong understanding of Claims and Encounter data.
- Strong command on SQL Server (T-SQL), SSIS and SSRS, and Databasedesign.
- Strong analytical/financial skills
- Proficient with MS Office, MS-Access, MS-Visio