Medicare Risk Adjustment Program Analyst, South San Francisco, CA
MEDICARE RISK ADJUSTMENT PROGRAM ANALYST
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Medicare Risk Adjustment Program Analyst. This Program Analyst engages with internal and external stakeholders to produce accurate and reliable reporting for monitoring and decision making purposes, manages new and ongoing analytics-related projects, assists in the management of data submission to HPSM’s regulators, and engages in continuous improvement efforts for the program and organization.
The essential duties and responsibilities will include the following:
- Provide analytic support to understand data-driven plan revenue, with a focus on Medicare risk scores and premium. Drive revision or development of reporting that reflect risk adjustment metrics or opportunities at the patient, provider, and population levels. Monitor existing reports and identify performance indicators, key metrics and influencing factors. Perform data analysis, create reports or presentations, and deliver reports to end users, as appropriate.
- Function as an organizational resource for Medicare data submission and reconciliation processes related to the RAPS and Encounter Data Submission (EDS) pathways. Contribute to maintenance of data submission integrity oversight and reconciliation efforts. Maintain working knowledge of Medi-Cal encounter data submission processes.
- Develop diagnosis coding and documentation training programs and provider facing tools. Complete and/or contribute reporting and analytic support to ongoing diagnosis coding and documentation quality assurance reviews and internal or external audits.
- Support management of supplemental encounter data intake and reporting processes. Identify opportunities for supplemental data submissions by external partners and ensure consistent quality and delivery of supplemental data.
- Propose and execute data submission and reporting improvement efforts. Coordinate with Claims, Information Technology and other internal and external business partners to analyze and resolve data submission issues at the organization, provider, and regulator levels.
- Deploy understanding of healthcare delivery system and Medicare HCC-related risk score methodologies and payment models, including: beneficiary and population level risk score calculation, data submission requirements and deadlines, key elements of data-driven revenue capture (ICD codes, CPT/HCPCS codes, dates of service, eligibility, etc.).
- As a key member of the Risk Adjustment team, maintain up-to-date knowledge of Medicare risk adjustment regulations and guidelines and proactively identify opportunities for continuous improvement. Support overall risk adjustment operations, including, but not limited to, internal and external audits (e.g., RADV), the development or revision of current policies and procedures, operational workflows, and desk procedures relevant to program operations.
- Other duties as assigned
Education and Experience:
- Bachelor’s Degree in Business or Healthcare Management, Policy or Administration, Public Health, Finance, or related field required. Master’s Degree preferred.
- Minimum 3 years related work experience, preferably data and/or business analysis in healthcare or managed care environment.
- Experience with Medicare risk adjustment subject matter required.
- Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
- Medicare risk adjustment payment models and related reporting.
- Medicare data submission pathways; encounter data experience a significant plus.
- Diagnosis coding & documentation standards; coding certification(s) a significant plus.
- Reporting and analysis specification development, methodologies and documentation.
- Change management, data driven decision-making and continuous improvement models.
- Medicare and/or Medi-Cal (or other Medicaid) managed care programs.
- Master changes in business and health care content and deploy subject matter expertise.
- Utilize quantitative skills to research and analyze data to inform decisions and develop solutions.
- Collaborate with internal departments to improve data quality and monitoring mechanisms.
- Take personal initiative and work independently, as well as part of a team.
- Continuously re-prioritize to accommodate new or revised business requirements.
- Work creatively and with attention to detail and data nuances.
- Communicate effectively, both verbally and in writing.
- Utilize strong interpersonal and customer service skills.
Starting Compensation Range: - Depends on Experience
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion (5%) of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: firstname.lastname@example.org or via fax: (650) 616-8039. File by: Continuous until filled. EOE
Submissions without a Cover Letter and Salary Expectations may not be considered.