Reporting to the Director of Risk Adjustment within the Finance Department, and working closely with the leaders of Commonwealth Care Alliance’s (CCA) Business Intelligence, Information Technology, Clinical Operations, and Claims Operations functions, the Senior Analyst, Risk Adjustment Program will be responsible for evaluating business operations directly linked to revenue capture. The Senior Analyst will be accountable for ensuring that data provided to external vendors and internal stakeholders is correct, complete, and timely. Further, the Senior Analyst will be responsible for identifying areas for improvement in business and technical processes which drive revenue capture. The Senior Analyst will possess expertise in risk adjustment methodologies, technical expertise in healthcare analytics, and experience in financial analysis with focus on Medicare risk adjustment. A minimum of 5 years’ experience in managed care or other healthcare environment in a technical analyst role.
• Prior experience with risk adjustment methodologies and risk revenue financial analytics required.
• Strong programming skills required (SQL at minimum).
• Experience with and aptitude for using data warehouse/data mart products.
• Strong knowledge of the healthcare delivery system and the key attributes of revenue capture (ICD codes, CPT/HCPCS codes, type of bill codes, place of service codes, dates of service, etc.).
• Comfortable with a high degree of independence within a rapidly transforming organization.
• Prior experience with encounter data submission a major plus. Essential Functions/Responsibilities:Provide analytic support to ensure accuracy of Medicare and Medicaid revenue, with a focus on Medicare risk-adjusted premium.
Develop new reporting initiatives and improve existing tools to track activities that impact revenue capture.
- Understand Medicare risk score methodology, including: risk score calculation, financial risk receivable calculations, Risk Adjustment Processing System (RAPS) and Encounter Data Processing System (EDS) processes and key regulator deadlines for data submission, RAPS and EDS Return Files and Error Files, understand eligibility, ICD coding, claims, and provider data.
- Analyze data flow and data integrity to identify areas for improvement in risk adjusted revenue.
- Complete routine quality assurance checks to ensure data accuracy and completeness and execute corrections as needed.
- Update, create, and maintain business process and technical workflow documents.
- Serve as a key technical subject matter expert for the organization.
- Ensure accurate data flow to and from external health assessment vendors. Track progress routinely through the creation of dashboard reports.
- Ensure accurate data flow to and from vendors responsible for encounter data submission and risk adjustment processing system data submission. Collaborate closely with IT, Business Intelligence, Financial Planning and Analysis, and Claims teams to improve and correct data, short and long-term.
- Create dashboards to track risk score capture by provider and clinical intervention. Assist in the creation of user guides and educational materials to ensure positive end-user experience.
- Identify missed opportunities for accurate revenue capture across the continuum of data collection and data transmission to CMS.
- Assist in the reconciliation of payment from CMS to CCA.
- Calculate financial impact of strategic risk adjustment program projects. Use findings to inform strategic priority setting.
- Alongside Director, create and maintain risk mitigation analyses to meet Regulatory requirements.
Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.
- As a key member of the Risk Adjustment team, maintain up to date knowledge of Medicare risk adjustment policies and methods. Contribute to updates to CCA data infrastructure and processes as needed.
- As a key member of the Risk Adjustment team, contribute to Program documentation, including required regulatory documentation.
- As a key member of the Risk Adjustment team, support the group in all routine payment quality assurance activities, including audits and chart reviews.