Remote Medicare Risk Adjustment Jobs in Raleigh, NC

Veradigm is a healthcare analytics and technology company that helps health plans and atrisk providers improve Risk Adjustment and Quality outcomes across HIX, Medicare Advantage, and Medicaid. With advanced analytics and realtime intelligence, we give clients clear visibility into member and provider activity so they can close documentation, coding, and quality gaps more efficiently.

The Veradigm Encounter Management Platform is a centralized solution that processes, validates, and submits encounter and supplemental data for Medicare, Medicaid, ACA, and other government programs. It streamlines ingestion, edit resolution, submission readiness, and CMS response handling, giving health plans and BPO partners a reliable, compliant way to manage largescale encounter operations.

Job Summary

The Systems Analyst works primarily with enterprise customers of Veradigm's Encounter Management Platform, proactively assisting them with post- sales installation, configuration, upgrade, troubleshooting and day to day operational management. Responsibilities include taking a proactive leadership role working with the Engineering team and Customers to triage and resolve highly complex, technical, and application-related issues which impact product performance in customer-specific environments, or issues that directly hamper a broader customer adoption of Veradigm's Encounter Management Platform. In addition to working with customers, the Systems Analyst will routinely partner with our Development, Sustaining Engineering and Sales Engineering organizations to resolve support issues, document bugs, provide UAT on product builds, and ensure that new and newly upgraded server installations are successful.

What you will contribute:

• Support encounter data reporting processes for EDPS, RAPS and the EDGE server, including tracking, reporting, and resolving rejections
• Conduct gap analysis and data validation, identifying possible issues in data submission and determining financial impact.
• Analyze and reconcile claims and encounter data which will include 837 EDI encounter files for EDPS, RAPS and Edge Server submission files
• Perform research in the encounter management system and liaison with the CSSC Helpdesk for exception resolution
• Be comfortable with raw data files in their native format and accessing these through various servers
• Partner with Product Support Engineers and development teams as necessary
• Assist development team with performance analysis and testing during release cycles for service packs, hot fixes etc
• Answer email and phone requests for help from customers
• Collaborate in virtual teamwork with other Product Support staff
• Host online troubleshooting and investigation sessions on customer's production environments
• Deliver a consistent, responsive and satisfying customer experience with each contact
• Collect all necessary problem details from customers to be able to effectively see the problem to resolution
• Successfully reproduce customer issues in a controlled test environment
• Follow standard operational procedures for case management
• Continuously improve troubleshooting skills, product expertise, and knowledge on related technical topics
• Perform ACA and MA Submissions for Clients
• Understand RAPS and EDPS filtering logic which CMS uses for Risk Adjustment and/or Risk Score calculations
• Monitor CMS data submission deadlines for both MA and ACA lines of business

The ideal candidate will have:

Academic and Professional Qualifications:

Bachelor's Degree in Health IT/Informatics/Management Information Systems or related field required

Experience:

• 2+ years of professional experience in Risk Adjustment data management
• Understanding of claims data, encounter response files, 837 EDI encounter files, EDGE/MA billing & business rules as well as MA filtering logic for EDPS
• Experience with CMS Submissions Process and EDI transactions
• Excellent time management and organizational skills necessary
• Prior experience troubleshooting performance problems that may have many underlying causes such as Disk, Database, Network, Messaging and other platform / 3rd party solutions
• Experience with managing product back end and webservices
• Ability to guide customers remotely through complex, multi-server deployments and upgrades for enterprise products
• Familiarity with EDI Standards such as X12, EDIFACT, HL7, NCPDP and knowledge of HIPAA transactions
• Prior knowledge of 837's along with various loops and segments and an understanding of the requirements set forth by CMS for EDPS submission files
• Working knowledge in SQL scripts is a plus
• Good written and verbal skills.
• Knowledge in CMS model changes is a plus
• Knowledge in CMS Risk Score and Risk Adjustment methodologies is a plus
• Knowledge in Medicaid is a plus

Travel Requirements:

Less than 5%

Compensation Range:

Compensation for this job is subject to market conditions, geographic considerations, the candidate's unique skills and experience, state and local laws, and budget. Our commitment to pay transparency is a testament to our dedication to creating a fair, equitable, and inclusive workplace. By continuously analyzing market trends, staying abreast of changes in state laws, and making budgetary adjustments accordingly, we strive to ensure that our compensation practices reflect the value we place on our associates' unique contributions and support their professional growth.

Enhancing Lives and Building Careers

Veradigm believes in empowering our associates with the tools and flexibility to bring the best version of themselves to work and to further their professional development. Together, we are In the Network. Interested in learning more?

Take a look at our Culture, Benefits, Early Talent Program, and Additional Openings.

We strongly advocate that our associates receive all CDC recommended vaccinations in prevention of COVID-19.

Visa Sponsorship is not offered for this position.

At Veradigm, our greatest strength comes from bringing together talented people with diverse perspectives to support the needs of healthcare providers, life science companies, health plans, and the patients they serve. The Veradigm Network is a dynamic, open community of solutions, external partners, and cutting-edge artificial intelligence technologies that provide advanced insights, technology, and data-driven solutions. Veradigm offers a comprehensive compensation and benefits package, including holidays, vacation, medical, dental, and vision insurance, company paid life insurance and retirement savings.

Veradigm's policy is to provide equal employment opportunity and affirmative action in all of its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity or expression or any other legally protected category. Applicants for North American based positions with Veradigm must be legally authorized to work in the United States or Canada. Verification of employment eligibility will be required as a condition of hire. Veradigm is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse and inclusive workforce.

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