Purpose Statement / Position Summary Risk adjustment is a method Medicare Advantage uses to determine the cost of care for patients. A higher score reflects a more complex patient population and thus, the reimbursement for care of these patients are higher. An accurate risk adjustment score ensures complete reimbursement. The Clinical Business Analyst, Senior role is to deliver analytics solutions for the Risk Adjustment department, leveraging the appropriate Business Intelligence tools for the type of analysis needed. This includes, but is not limited to, static reports, dynamic reports, self-service portals, data exploration, data visualization, and statistical or predictive analysis tools. A focus will be on monitoring and mitigating any potential encounter submission gaps which will prevent accurate data to be submitted to CMS. This role will be capable of developing complete solutions of advanced complexity, incorporating source data into existing or new data structures, enriching Master Data Repositories and Data Dictionaries in the process, and providing appropriate end-user interface(s) to meet the clinical or business intelligence needs of the customer. Leads initiatives or small projects within the team, developing management and leadership skills.
In collaboration with other members of the Data Strategy & Reporting team, adheres to Lean and Agile-based standard work processes to ensure that the hallmark of this team’s efforts are timely, defect-free deliverables. Mentors more junior staff members. Essential Functions and Responsibilities of the Job
Ensure data is successfully submitted on time, in the correct format
Compare Encounter Data Submissions (EDS) to the Risk Adjustment Payment System (RAPS) data to analyze variances between the two systems and determine impact of the EDS process on revenue
Reconcile errors and analyze final submissions reports
Initiate process improvements to improve submissions
Compare monthly health plan diagnosis and encounter files to our submitted data to identify conditions not accepted
Work with the Finance department to compare sweeps and capitation files for our MA population and confirm it is consistent with projected expectations
Analyze trends in submission patterns between different provider entities and report changes to Risk Adjustment Director
Understand the CMS Risk Adjustment model and keep up to date with changes to this model
Follow company policies, procedures and directives
Exhibit professionalism in the workplace at all times
Exhibit strong work ethics
Ability to prioritize and multitask concurrent initiatives
Proven experience working with healthcare data, including RAF
Eight years’ experience with organizing, analyzing and producing analytic solutions for others to consume
A working knowledge of SQL (structured query language) and a fundamental knowledge of database design principles.
Demonstrated success in the development, analysis, interpretation, and management of a variety of complex data sources.
Demonstrated proficiency with industry standard BI or analytical tools and technologies.
Preferred but not required: experience with statistical software systems such as SAS, SPSS, R, Python, etc.
Bachelor’s degree in Computer Science, Business Administration, Statistics or the like