Senior Fraud Risk Analyst Jobs in Oregon (NOW HIRING)

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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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Senior 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), HEDIS and Quality performance as well as other data within a given system. The Senior 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 and quality improvement, maintain required documentation, and ensure compliance to all applicable laws, guidance, and regulations. Assume lead role on specified projects. Projects are completed with cross-functional teams of peers and business partners. This includes interaction with provider partners with the intent of informing them on performance and educating on best practices in risk adjustment. The Senior 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.
• Develop and maintain reporting capabilities to measure and forecast risk scores & quality metrics, monitor suspecting model performance, and identify areas of improvement
• Maximize risk adjustment revenue and quality bonus payments by driving data integration and analytics to properly capture and improve the health status of PacificSource members.
• Validate data integrity and collaborate with technical teams to improve data pipelines and business logic for identified areas of opportunity
• Identify and lead internal subject matter experts in regular meetings to identify and rectify various data submission and adjudication errors related to risk adjustment and quality data submission.
• Develop and maintain data sets leveraging internal data, response data from regulatory entities (including but not limited to: EDGE files, MMR, MOR, RAPS Response, MAO-004, PSV, PLD, etc.), and ancillary data sources to be consumed across the enterprise.
• Demonstrate mastery 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. Perform root cause analysis to maintain high integrity data and processes to minimize discrepancies and gaps.
• Maintain a high level of familiarity of current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings. This includes review of regulatory announcements, attending educational sessions and opportunities provided by regulatory entities or within the industry.
• Develop, maintain, and report out on actionable metrics related to risk adjustment and HEDIS to incorporate quality/health outcome metrics where applicable.
• Prepare new and review existing specifications, project plans, and other internal procedural documents. Ensure users and partners understand nature of work being performed, as well as timeframes and milestones. Provide regular status updates to supervisors and stakeholders.
• Provide support as needed for projecting annual receivable amounts, preparing projections related to pricing efforts, and predicting cost utilization as it relates to risk adjustment.
• 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.
• Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Five years' experience in data analytics or software development required, to include at least three years' experience in Health Plan required. In depth risk adjustment and/or HEDIS experience required, including risk models, CMS guidelines, regulatory data submissions, retrospective and prospective programs, interpreting health care regulatory/accreditation requirements and data validation audits. Expertise in Microsoft Excel and SAS/SQL is required. Experience in leading projects and project teams required. Familiarity with Medicaid risk adjustment and CMS 5-Star required. Familiarity with Risk Adjustment Documentation, Coding practices and NCQA quality metric experience preferred. Equivalent work and education experience will be considered.

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

Knowledge: Expert-level analytical and problem-solving abilities are required. Mastery of theories and applications of computer programming required. 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. Excellent communication skills, both verbal and written, particularly the ability to convey technical information in an accessible and understandable manner. 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:

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Customer Loyalty

Building Strategic Work Relationships

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 20% of the time with some overnight travel.

Skills:

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

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$74,601.93 - $126,822.77Our 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.