Risk Adjustment Analyst
PacificSource

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Risk Adjustment (RA) Analyst assists in the accurate and comprehensive data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable populations. This position leverages available tools and knowledge of the applicable risk models to optimize data submission as it pertains to Hierarchical Condition Categories (HCCs) and other data within a given system. The RA Analyst will collaborate and coordinate with internal and external partners to minimize submission and response errors, provide thorough oversight of vendor partners, accumulate and report out on pertinent data sets, develop and improve processes related to risk adjustment, maintain required documentation, and ensure compliance to all applicable laws, guidance, and regulations. This includes interaction with provider partners with the intent of informing them on performance and educating on best practices in risk adjustment. The RA Analyst will provide mentorship to less experienced team members. In addition, this position influences decision making by leadership and provides recommendations regarding potential improvements to risk adjustment processes and outcomes.

Essential Responsibilities:

• Recommend and guide process improvements that will optimize risk adjustment factor increases while minimizing inaccurate capture of disease burden.
• Identify, analyze, interpret and communicate risk adjustment trends to be consumed by provider partners and related entities.
• Responsible for maintenance of existing reports, development of new reports to help ensure company goals are met, as well as other ad hoc requests as needed.
• Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment data submission.
• Develop and maintain data sets leveraging internal data, response data from regulatory entities (EDGE files, MMR, MOR, RAPS Response, MAO-004, etc.), and ancillary data sources to be consumed across the enterprise.
• Demonstrate proficiency in running all applicable risk models including the various CMS models for Medicare Advantage members, the HHS model for Commercial ACA members, and others as needed.
• Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy.
• Assist with all pertinent audits, including RADV, through preparation activities and documentation.
• Assist with root cause analysis to maintain high integrity data and processes to minimize discrepancies and gaps.
• Gain knowledge of current CMS regulations and announcements affecting risk adjustment. This includes review of regulatory announcements, attending educational sessions provided by regulatory entities, as well as staying apprised of educational opportunities within the industry.
• Assist in developing, maintaining, and reporting out on actionable metrics related to risk adjustment and incorporating quality/health outcome metrics where applicable.
• Work with changing data, file specifications, and internally coordinate releases and modifications through approved procedures.
• Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes.
• Work with internal teams, provider partners, and vendor partners as needed to support risk adjustment activities.
• Provide mentorship, leadership, and training to less experienced risk adjustment analysts.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: Three years' experience in data analytics related to health information required. Experience in a Health Plan preferred. In depth Medicare or Commercial ACA risk adjustment experience required, including risk model and CMS guidelines, RAPS/EDS & EDGE data submissions, retrospective and prospective programs, and RADV audits. Expertise in Microsoft Excel and SAS/SQL is required. Experience in leading projects and project teams preferred. Medicaid risk adjustment experience preferred. Familiarity with Risk Adjustment Documentation and Coding practices preferred. Medicare Stars and/or HEDIS experience preferred. Equivalent work and education experience will be considered.

Education, Certificates, Licenses: Bachelor's degree in Mathematics, Statistics, or similar research related field required. Advanced degrees preferred.

Knowledge: Excellent analytical and problem solving abilities are required. Mastery of theories and applications of computer programming required (SAS and VBA are the primary tools used). Experience with and understanding of risk adjustment model. Ability to keep current with changing technologies, work independently under limited supervision, exercise initiative within established procedural guidelines, and prioritize work to meet established deadlines a must. Ability to communicate clearly and concisely, both orally and in writing when making presentations and creating documents. The ability to establish and maintain effective work relationships, exercise good judgement, and demonstrate decisiveness and creativity. Read, understand, and interpret documents of complex subject matter.

Competencies:

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel estimated to be 10% of the time.

Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

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