Risk Adjustment Analyst I/II/III/IV - Rochester, United States - Excellus BlueCross BlueShield Inc

Description

** Risk Adjustment Analyst I/II/III/IV **

**Job Category****:** Non Manager **Requisition Number****:** RISKA006549 Showing 1 location The Risk Adjustment Analyst performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS and NYS standards and modeling financial impacts of changes in risk adjustment data and methodologies. This position interacts with analyticalcoding staff in all regions, vendors, as well as internal departments such as Finance, Actuarial, Operations, Network Management, Provider Contracting, Legal, and Compliance. Upper levels of the role also interact with external agencies like BCBSA, AHIP, NYS DFS and CMS as well as outside consultants. Develops financial projections and conducts analysis for risk adjustment projects including retrospective chart review and prospective initiatives. The Risk Adjustment Analyst gathers, standardizes, and consolidates financial claims, membership and premium data into data sets that are used for risk adjustment analytical and reporting needs. Analyst should leverage industry resources to increase knowledge and improve ROI of risk adjustment activities . Maintains current knowledge of risk adjustment models such as: CMS Hierarchical Condition Categories (HCC) and RxHCCs, HHS HCCs and Clinical Risk Groups (CRGs) along with other open source and third-party models. Calculates ROI for risk adjustment vendors, initiatives, and projects. Assists in the preparation of risk adjustment analyses. Develops ad hoc reports to supplement risk adjustment processes through query building and data extraction. Assists and/or supports other Risk Adjustment teams or Health Plan departments to complete projects or tasks as needed. Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements. Level II (in addition to Level I essential responsibilities/accountabilities): Shares knowledge with newer department employees. Assists in the development of risk adjustment analyses concerning complex issues and trends, coordinates with staff. Proposes and assists in development of risk adjustment process improvements and automation of processes utilizing data integration software. Level III (in addition to Level II essential responsibilities/accountabilities): Develops risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff. Level IV (in addition to Level III essential responsibilities/accountabilities): Leads risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff. Minimum Qualifications: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. Bachelors degree in Math, Economics, Actuarial Science, Computer Science, general Sciences or allied field and a minimum of one year relevant experience required. In lieu of experience, actuarial exams, technical certifications or programming coursework are required. Exceptional analytical skills, with strong verbal and written communication skills. Strong organizational skills and ability to prioritize, multitask, and work in fast pace environment. A strong understanding of health insurance & health insurance products, managed care, accounting principles, the competitive market, the legislative environment, and any regulatory issue affecting the Health Plan is expected to be acquired. Focused on meeting the expectations and requirements of both internal and external customers. Self-motivation, initiative, and an ability to perform under pressure with little supervision. Strong PC skills including Microsoft Office Suite, (Excel, Access, Word, PowerPoint, Outlook, Teams) and familiarity with data integration tools, such as SAS, SPSS, R, Power BI, Tableau, etc., required. Experience with programming languages such as base SAS, SQL, R, Python, C, C++, C#, Java, or similar languages, preferred. Familiarity with medical claims and medical terminology preferred. Level II (in addition to Level I minimum qualifications): Three years actuarial or related industry experience required OR o Two years actuarial or related industry experience and two actuarial exams is required. 1 year of experience with data integration tools and/or programming languages. SAS Base Certification preferred. Highly proficient computer skills including Excel, Word, SAS, Cognos, PowerPoint and intermediate SAS or equivalent programming language proficiency. Knowledge and understanding of HHS-HCC, CMS-HCC or CRG Risk Adjustment Models Level III (in addition to Level II minimum qualifications): Six years Risk Adjustment or related industry experience required OR o Three years actuarial or related industry experience and four actuarial exams or SAS Certification I. Strong ability to recognize and automate repetitive tasks. Ability to perform complex modeling independently. Advanced SAS programming or equivalent programming proficiency and experience with data integration & Business Intelligence tools preferred. Project Management/Process Improvement knowledge preferred. Level IV (in addition to Level III minimum qualifications): Ten years Risk Adjustment or related industry experience required OR o Four years actuarial or related industry experience in conjunction with ASA & MAAA credentials or SAS expertise and experience with data mining and forecasting. A strong understanding of non- Risk Adjustment functions such as Actuarial, Care Management, Accounting, Provider Contracting, Network Management, Product Development, etc., and how they impact Health Plan operations and financials. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. **Skills**

**Education**

**Preferred**

Bachelors or better in Actuarial Science.

Bachelors or better in Computer Science.

Bachelors or better in Economics.

Bachelors or better in Mathematics.

**Experience**

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractors legal duty to furnish information. 41 CFR c)