Manager Hcc Risk Adjustment Jobs in Maryland (NOW HIRING)

Resp & Qualifications

PURPOSE: 
The purpose of a Sr. Data Analyst is to support ACA risk adjustment processes, including EDGE server analysis and submission validation. Ensure accuracy and integrity of risk adjustment performance metrics through proactive analysis and validation of data sources including claims, enrollment, provider, and EDGE submissions.  Analyze and interpret CMS and HHS risk adjustment methodologies to support risk score calculation and financial performance insights.
ESSENTIAL FUNCTIONS:

• Engages in data exploration using various programming languages (reading and writing code), requiring advanced knowledge of multiple database structures. Understand CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDGE processes and key regulatory deadlines for data submission.  Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue.
• Collect, analyze, and interpret data to glean insights, and develop business appropriate recommendations.
• Assists in designing an overall suite of analytic capabilities and actionable reports to 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 maximizing reimbursement based on the CMS-HCC (Hierarchical Condition Code) model. Perform data mining of claims and data to identify trends, data issues and members with missing HCCs.
• Research and analyze data flow across complex data ecosystem including operational and analytical data platforms.  
• Serve as an expert resource supporting data questions and issues from stakeholders and driving to resolution.  Collaborate across business units to coordinate the development of financial dashboards and models to identify and track revenue and ROI trends. Work with team members to understand and monitor the financial impact of risk adjustment programs. Contribute to developing materials and presenting key updates to leadership regarding risk adjustment programs and provider and member engagement initiatives.
• Lead in the design, development, validation and delivery of data to provide insight into business decisions.  Conduct analyses to develop a comprehensive understanding of a providers risk score trends, EMR systems and contracting arrangements to recommend and generate provider-specific engagement plans. Oversee the analysis and interpretation of provider-specific results and risk score trend information. Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy and identification of member health conditions. Update, create and maintain business process and technical workflow documents.
• Manage the collection of business and technical requirements from Stakeholders to deliver data driven solutions. Produces technical documentation that is consistent with professional standards.
• Be a resource and mentor to junior level staff.

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 in Data Science, Mathematics, Computer Science, Statistics, Business or related field 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 in an analytical/quantitative role.
Preferred Qualifications:

• Experience in Healthcare Industry.
• Hands on experience with Big Data/NoSQL Platforms with experience delivering production projects at scale. 
• Experience with SAS, SQL, Python or other programming language.
• Experience with ACA HHS risk score methodology, including risk score calculation and financial risk receivable calculations.
• Experience with EDGE Submission Error Analyses and reporting.

Knowledge, Skills and Abilities (KSAs)

• Quantitative, analytical and problem-solving skills.
• Knowledge and understanding of analytical tools, languages, applications, platforms.
• Excellent communication skills both written and verbal.
• Ability to learn quickly and take direction.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: 87,264 - 173,316

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 responsibilities 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).

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.

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

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