The purpose of the Risk Adjustment Analyst position is to coordinate and drive the design, build, documentation, and support of the Financial and Business reporting requirements for the Medicare and Commercial Risk Adjustment Programs; to work closely with end-users to gather reporting requirements and analyze internal reporting tools; to ensure proper testing and validation of data elements on the finished product; to participate in the resolution of reporting problems; to build, perform, and maintain reporting analysis and modeling utilizing a variety of systems; to provide analytical support on various strategies to ensure company goals are met; to propose opportunities in maximizing our reimbursement based on CMS-HCC Model and Methodology; to propose innovative approaches to create or improve automation and optimize processes where appropriate; to lead cross-functional analytical and operational teams toward the goal of improved risk adjustment scores; and, as appropriate, to assist with the support of the Medicare Advantage Risk Adjustment and Payment System, Commercial Risk Adjustment EDGE Server and ultimate Centers for Medicare & Medicaid (CMS) Reimbursement.
Nature and Scope:
Under the direction of the Risk Adjustment Supervisor, this position develops and coordinates the risk adjustment improvement and reporting efforts, for Hometown Health’s Medicare and Commercial products utilizing a variety of source systems and development tools. Included within the scope of this position, the incumbent 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. General knowledge of Health Insurance, Claims Data, Managed Care, Benefit Design, Nevada Revised Statutes (NRS), Nevada Administrative Codes (NAC), Medicare Advantage Prescription Drug plans (MA-PD) and Federal Regulations.
2. The job function requires an ongoing, direct communication with Managers and Directors in all departments and the ability to lead non-subordinates toward the common goal of improving risk adjustment scores.
3. The incumbent must have the ability to analyze user requirements and translate data into business context in order to define specific, goal oriented action plans and lead projects to completion by contributing to database creation, statistical modeling, and report specifications.
4. All summary and analysis reporting projects must be mechanically, statistically and theoretically accurate.
5. Additional duties may include working with outside vendors and healthcare providers to provide or collect data or perform system updates as needed.
6. This position also acquires and maintains comprehension of industry specific knowledge to initiate, coordinate, and provide expertise related to risk adjustment and decision support analytic projects.
7. Major challenges of this position include ensuring the Financial Business reporting solutions and improvements are actionable, accurate, timely, and meaningful and that the cross-functional teams complete designated tasks necessary to achieve the common goal of improved risk adjustment scores.
8. Most of the work in this position will be performed independently or as part of a self-directed work team. Minimal detailed instruction will be given.
9. This position will have access to propriety information. This mandates high standards of professionalism, communications, performance, and respect for confidentiality. Philosophy consistent with the corporate culture, Fundamentals and Standards of Conduct of Renown Health. It is common to encounter potential hazards in the healthcare environment. Some of these hazards could include, but are not limited to: Radiation, Toxic Chemicals, Biological Hazards, Heat, Noise, Dust and Stress. Renown Health has a Safety Management Program in place addressing these issues. This position does not provide patient care.
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.
Minimum Qualifications: Requirements – Required and/or Preferred
Education: Must have working-level knowledge of the English language, including reading, writing and speaking English. Four-year degree from an accredited college preferred. Bachelor’s degree in Management Information Systems, Business, and Computer Science strongly preferred, but not required. Healthcare Administration or other Healthcare field will receive preference.
Experience: Minimum of two years’ experience with applications as a clinical or financial user or technical specialist and at least one year’s experience as a report developer. Experience with Medicare Advantage plans or Medicare Managed Care preferred. Preference will be given to individuals with experience in healthcare systems. Experience with SAS, SQL, EPIC, Clarity and Reporting Workbench is desired. Knowledge of ICD-9/10 codes preferred.
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. Typing 35 WPM.