Job Details

JOB SUMMARY:

The Manager of Risk Adjustment is responsible for directing a team of data analysts in providing analytical support and various cost and quality metrics to both internal and external customers. Facilitates submission of encounter records to regulatory agencies, resolution of rejected records and reconciliations. Facilitates submission of data for CMS and other regulatory audits. Oversees calculation and tracking of risk factors and analyzes trends in risk scores. Performs analysis and makes recommendations for improving risk coding accuracy. Works with risk adjustment vendor and medical groups to improve risk coding accuracy and submission processes. Facilitates data warehouse maintenance using internal and external data source. Supervises and directs personnel in the preparation of various production and ad hoc reports.

KEY RESPONSIBILITIES:

• Organizes and lead the team responsible for risk score tracking and improvement.
• Maintains internal risk adjustment models using published documentation from CMS.
• Manages projects, including creating and leading a team of analysts, interaction with other departments and outside parties. Perform quality review of work product produced by assigned analysts.
• Conducts major analytical projects without immediate supervision, including all aspects from programming to analyzing and abstracting information into written reports and possible oral presentation.
• Oversees training of new analysts and professional development of supervised analysts.
• Supervises and performs advanced analytical modeling for IPPS and OPPS Pricers and other models as needed. Oversees provider contract modeling.
• Facilitates submission of encounters to regulatory agencies (CMS Encounter Data and Edge Server Data).
• Oversees other data submission to regulatory agencies including audit universes, Part C and D reporting submissions, and other submissions as required.
• Perform other duties as assigned.

QUALIFICATIONS:

• Ability to conduct concurrently multiple analyses without immediate oversight.
• Ability to manage multiple projects, including creating and leading a team of analysts, interaction with other departments and outside parties.
• Ability to apply advanced actuarial, mathematical and statistical techniques and principles into the analysis of financial and health related data.
• Possess strong oral and written communication skills.
• Successful completion of Health Care Sanctions background check.
• Proficient in Microsoft Office applications.

EDUCATION/EXPERIENCE:

• Bachelor's degree in Mathematics, Statistics, Economics, Actuarial Science required.
• Proficiency in SAS, SQL, or other Analytical Software.
• 6 plus years analytical experience; preferably in a Managed Care or Healthcare environment.
• 4-6 years management experience strongly preferred.
• Experience with various risk adjustment models including the CMS Medicare model, CMS ACA Model and 3rd party software strongly preferred.