Senior Risk Adjustment Analyst - Business Ops (Hybrid)
Job Description
Resp & Qualifications
PURPOSE:
The Senior Risk Adjustment Business Operations Analyst assumes a pro-active approach in ensuring the accuracy and integrity of key risk adjustment performance metrics through coordination of analytical processes, investigation and interpretation of regulated markets risk score methodologies, risk score calculations, enrollment, submissions, medical and pharmacy claims, and provider data. Incumbent is responsible for performing analyses and problem resolution to meet business operational requirements for Medicare Advantage(MA), Affordable Care Act (ACA) & Medicaid Lines of Business (LOB). Additional responsibilities include establishing and maintaining business policies, process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company, as well as external entities, providing coordination and support as required. We are looking for an experienced professional in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS:
- Maintain the Business Operational Plan for risk adjusted segments to support audit readiness. Update, create and maintain business process and technical workflow documents. Monitor and reconcile Business Policies and Procedures as mandated by LOB. Maintain dashboards and reporting delivering results of analyses to improve awareness and understanding of risk adjustment and identification of member health conditions.
- Understand CMS risk score methodology, including risk score calculation, financial risk calculations, submission processes and key regulatory deadlines for data submission. Understand the impact of the claims on the risk adjustment revenue including interpretation of HHS/CMS/Medicaid guidelines, monitoring and determining the impact of any changes to the model and supporting team in planning for changes.
- Assists in designing an overall suite of analytic capabilities and actionable reports to monitor internal performance, oversee vendors, solve problems, provide data-driven guidance, and monitor risk adjustment performance. Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in accurate & complete reimbursement based on the applicable model. Perform data mining of claims and data to identify trends, data issues.
- Support project & program management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support management in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS: Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Experience: 5 years experience with data analysis which includes use of statistical methods, experience with programming language. Knowledge, Skills and Abilities (KSAs) Salary Range: $64,080 - $127,270 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). Department Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Where To Apply Please visit our website to apply: www.carefirst.com/careers Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. Sponsorship in US Must be eligible to work in the U.S. without Sponsorship #LI-NH2
Resp & Qualifications
PURPOSE:
The Senior Risk Adjustment Business Operations Analyst assumes a pro-active approach in ensuring the accuracy and integrity of key risk adjustment performance metrics through coordination of analytical processes, investigation and interpretation of regulated markets risk score methodologies, risk score calculations, enrollment, submissions, medical and pharmacy claims, and provider data. Incumbent is responsible for performing analyses and problem resolution to meet business operational requirements for Medicare Advantage(MA), Affordable Care Act (ACA) & Medicaid Lines of Business (LOB). Additional responsibilities include establishing and maintaining business policies, process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company, as well as external entities, providing coordination and support as required. We are looking for an experienced professional in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS:
- Maintain the Business Operational Plan for risk adjusted segments to support audit readiness. Update, create and maintain business process and technical workflow documents. Monitor and reconcile Business Policies and Procedures as mandated by LOB. Maintain dashboards and reporting delivering results of analyses to improve awareness and understanding of risk adjustment and identification of member health conditions.
- Understand CMS risk score methodology, including risk score calculation, financial risk calculations, submission processes and key regulatory deadlines for data submission. Understand the impact of the claims on the risk adjustment revenue including interpretation of HHS/CMS/Medicaid guidelines, monitoring and determining the impact of any changes to the model and supporting team in planning for changes.
- Assists in designing an overall suite of analytic capabilities and actionable reports to monitor internal performance, oversee vendors, solve problems, provide data-driven guidance, and monitor risk adjustment performance. Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in accurate & complete reimbursement based on the applicable model. Perform data mining of claims and data to identify trends, data issues.
- Support project & program management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support management in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS: Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Experience: 5 years experience with data analysis which includes use of statistical methods, experience with programming language. Knowledge, Skills and Abilities (KSAs) Salary Range: $64,080 - $127,270 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). Department Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Where To Apply Please visit our website to apply: www.carefirst.com/careers Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. Sponsorship in US Must be eligible to work in the U.S. without Sponsorship #LI-NH2
About CareFirst BlueCross BlueShield
Named by the Ethisphere Institute as one of the “World’s Most Ethical Companies” for 10 consecutive years.
CareFirst. It’s not just our name. It’s our promise. Over 3.5 million people trust us with their healthcare needs, and we take this responsibility seriously.
Our vision for healthcare is clear. Quality care should be easy to afford, easy to use and available to everyone. And what we’re building for you is exactly what we expect for ourselves and those we love.
Every day, we make a meaningful difference in the communities where we live and work. We solve real problems for the people we serve with equal parts empathy and urgency—simplifying the complex, delivering tailored solutions and stepping forward with new ideas.
RECRUITMENT FRAUD NOTICE: CareFirst is aware of an increase in fraudulent job offers being made on behalf of our recruitment team. Legitimate CareFirst recruiters will always contact you from an email address ending in “@carefirst.com” and will never ask for a payment in exchange for a job opportunity or ask you to submit sensitive personal information via email, phone, or text.
COVID-19 VACCINATION NOTICE: As a leading healthcare organization, it is our responsibility to do our part to help end this pandemic and protect the health and well-being of our members, workforce, communities, businesses and partners. Our recruiters continue to fill open positions. Interviews and other processes are being modified to protect the safety of our candidates and team members. Effective November 1, 2021, COVID-19 full vaccination is required for all employees, including those who work remotely today or in the future. CareFirst will comply with all state and local laws regarding vaccine mandates. Medical and religious exemptions will be made where appropriate using our standard vaccine exemption processes.
Independent licensee of BCBSA.
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