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Job Summary
This position is responsible for aiding HCSC’s IFM risk adjustment operational management and analytics activities and functions. Operational areas include but are not limited to data management, data submissions, reject remediation, data reconciliation, data reporting and analytics, performance management, vendor management, as well as, interfacing with federal regulatory agencies if/when applicable.
Job Responsibilities:
• Acts as lead in various activities such as risk adjustment encounter data collection, processing, submission, small/medium/large projects, report generation, and data reconciliation efforts ensuring that data is processed and submitted according to State and/or CMS guidelines and requirements.
• Conducts business analysis and recommends solutions to leadership
• Analyze encounter data to identify trends, and conduct root cause analysis; develop improvement plans, organize cross-functional teams and develop high-quality output for internal and external constituents to address identified issues
• Provides guidance and training to other staff members as needed
• Monitors vendor performance and guiding them through issues, areas for improvement, and priorities
• Create reports, insights and analytics in support of the business.
• Create specifications for reports and analysis based on business needs; possibly providing consultation to users and working on cross-functional teams to address business issues.
• Produce datasets and reports for analysis using system reporting tools; possibly performing research and assisting in analyzing data related to the division’s strategic initiatives and broader research needs.
• Partners with vendors, team members, provider groups, etc. to ensure all CMS and/or State guidelines for risk adjustment data capture and contractual service level agreements are met.
• Serves as a Subject Matter Expert for other departments, providers, projects, and committees
• Performs any other job-related duties as assigned.
Required Job Qualifications:
- Bachelors or Advanced degree (or 4 years’ experience in lieu of degree) in Business Administration, Finance, Statistics, Healthcare Administration
- 3-5 years’ experience working in Healthcare industry in Medicaid and/or Medicare Encounter operations, risk adjustment or related operations.
- Experienced in query design/development (e.g. SAS, SQL, etc.) and/or relational database understanding
- Knowledge of Medicare and/or Medicaid Encounter Data System and understanding of 837-5010 and/or other standard encounter file formats
- Experience working with healthcare data specific to risk adjustment and/or related functions
- Proficient/advanced in MS Office (Excel, PowerPoint, Access, etc.) to derive effective presentations & exhibits for leadership
- Strong interpersonal, organizational, communication, and workflow skills
- Willingness and ability to travel approximately up to 25
Preferred Job Qualifications:
- Experience with risk adjustment encounter file preparation and remediation (e.g. 837 5010 files, RAPS returns/submission files, EDPS MAO-002, 277CA, and/or 999 file, MAO-004, or EDGE files etc.
- Experience with Medicare and/or Medicaid risk adjustment encounter management, reporting and requirements from either a payer or vendor a big plus
- Knowledge of and experience in Medicare and/or Medicaid risk adjustment functions, regulations, and other related activities
- Experience with databases as well as interpretation and manipulation of related healthcare data (e.g. claims, enrollment data etc.)
- Knowledge of encounters within other lines of business including Exchange/ACA, Medicaid, and/or Medicare Advantage
- Knowledge of HCC coding, risk adjustment
This is a Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state.
Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!
HCSC Employment Statement:
We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
Base Pay Range
$53,500.00 - $118,100.00
