Risk Adjustment Analyst

Under the direction of the Manager Risk Adjustment, will support The Health Plan’s risk adjustment and coding management goals with regard to the risk adjustment models. The position will be involved in developing, coordinating, and analyzing the impact of various activities used to support risk adjustment optimization. This would require evaluating and analyzing the effectiveness of prospective and retrospective programs, including reviewing claim/member/provider data. The Risk Adjustment Analyst will need to be able to work effectively with other team members within the organization in order to close clinical care and diagnosis coding gaps. This will help to ensure complete and accurate capture of revenue, based on the risk adjustment models.

Required:

1. College degree or a combination of education/experience in the health care industry.
2. Computer experience with Microsoft Word, Excel, Power Point and Outlook.
3. Strong organizational, verbal and written communication skills.
4. Knowledge of the health care system.
5. Excellent ability to work independently as well as part of a team.

Desired:

1. Certified Coder.
2. Prior Managed Care experience.
3. Medical terminology.
4. Knowledge of ICD and CPT coding (prefer certification).
5. Familiar with medical and hospital claims.
6. Familiar with prescription coding (NDC).

Responsibilities:

1. Participate in submission, monitoring, and error management of encounter data to the CMS, BMS, and the EDGE server.
2. Perform periodic and ad hoc analysis utilizing complex spreadsheets and systems by developing new and innovative approaches.
3. Assist with provider education and training on risk adjustment methodologies, documentation and coding in an effort to close clinical care and diagnosis coding gaps.
4. Assist with developing and implementing risk adjustment activities and programs.
5. Coordinate the annual retrospective medical record review.
6. Serve as liaison with vendors and partners on all aspects of risk adjustment and related projects.
7. Attend continuing education classes/seminars to maintain professional and technical knowledge of CMS requirements.