Rancho Mirage, California
Stockton, California
Loveland, Colorado
San Diego, California
Posted: 03-Oct-25
Location: Remote,
Categories:
Internal Number: 25017147
- JOB SUMMARY
The Risk Adjustment Analyst Sr is responsible for monitoring and oversight of the end-to-end encounter management workflow. This position analyzes complex encounter inbound/outbound process issues, using data from internal and external sources to provide insight to decision-makers. This role supports program management activities around risk adjustment data management and submissions to CMS. This role may require some domestic travel to support network partnerships and new strategic implementations.
ESSENTIAL FUNCTIONS OF THE ROLE - Responsible for documenting, monitoring, and analyzing the end-to-end encounter life cycle., inbound and outbound encounter process.
- Monitors and oversees the end-to-end claims encounter management workflow.
Identifies and interprets encounter data, submission requirements and performance metrics per the regulatory and health plan guidelines.
- Performs analysis and reporting activities related to risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics.
- Analyzes claims and supplemental data to identify reporting gaps, risk gaps and/or sources of incorrect and incomplete diagnostic data.
- Using data from internal and external sources, analyzes complex encounter inbound/outbound process issues to provide insight to decision-makers.
- Researches and documents all encounter errors in established systems(s)/database(s) with appropriate statistical trend analysis.
- Performs root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry standards.
- Collaborates across various departments to design and implement any business process and/or systems changes to meet encounter data processing and submission goals.
- Communicates regularly with management on issues discovered through research efforts.
- Develops various encounter related reports (i.e., exception reports, performance reports, root cause analysis outcome reports, etc.) and distributes them to appropriate departments for error resolution, follow up and performance monitoring.
- Participates in the workgroup to resolve encounter data and process issues.
- Analysis and forecasting of risk adjusted revenue PMPM by contact, plan and member cohorts.
- Perform analysis and reporting activities relating to risk score calculation. claims/encounters data submission, chart review programs and audits, and related performance metrics.
- Performs various financial analysis such as revenue forecasting and ROI.
- Contributes to program improvement by designing and implementing business process and system changes, collaborating to resolve encounter data and process issues and managing policy and procedure documentation.
- Oversee updates to department policies and procedures regarding risk adjustment data management.
- Remain current on CMS Risk Adjustment models and data collection requirements.
KEY SUCCESS FACTORS
Advanced knowledge of SQL, MS Excel, MS Access, MS Word, MS Visio and MS PowerPoint. Using SQL, able to design and run intermediate to complex queries and reports from multiple databases.
Able to independently gather, interpret and analyze data for the purpose of identifying trends, problems and opportunities for improvement.
Excellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.
Able to work under pressure, adhere to deadlines and know when to escalate information and issues.
Highly motivated and able to work with minimal guidance, independently and as a team participant.
Outstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.
Ability to work in a high paced environment independently and with cross functional groups.
Knowledge of ACA, Medicare, Medicaid, MCO, TPA business requirements preferred.
Experience with healthcare encounters, enrollment and pharmacy data preferred.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
- EDUCATION - Bachelor's in Quantitative discipline such as finance, economics, or mathematics or 4 years of work experience above the minimum qualification
- EXPERIENCE2 Years of Experience in Healthcare Analytics
- 2 years working with ACA and Medical Claims, MMR, MOR, MAO-002, MAO-004 and RAPs/EDS data
Experience with Healthcare claims, enrollment and pharmacy data is preferred
- Knowledge of ACA, Medicare, and TPA business requirements is a plus.
Skills/Abilities:
- Excellent data manipulation, communication, analytical and statistical skills are required.
Must be comfortable with SQL, MS Excel, MS Access, MS Word, MS Visio and MS PowerPoint.
Must have excellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.
Must have the ability to work under pressure, adhere to deadlines and know when to escalate information/issues.
Must have a high level of self-motivation and with little guidance/supervision.
Must be able to work both independently as well as a team participant.
Must have outstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.
Must have strong interpersonal skills
Ability to independently gather, interpret and analyze data
Ability to extract data from database using SQL
- Ability to design and run intermediate to complex queries and reports
- Ability to identify trends, problems, and opportunities for improvement
Ability to work in a high paced environment independently and with cross-functional groups