Job Summary:
The Senior Manager, Medical Risk Adjustment Analytics is responsible for the day to day operations of the risk adjustment function across all lines of business for the organization related to identification of member level risk opportunity, assignment of member level intervention approaches, risk adjustment data analytics and tracking ROI performance at an intervention level.
Essential Functions:
- Analyzes member information to ensure the Risk Adjustment Factor accurately reflects the membership health profile
- Develops and implements processes and procedures to ensure the accuracy and completeness of the Medicare Risk Adjustment, Medicaid and ACA/Marketplace data, and to ensure compliance with all CMS and State regulations and guidelines
- Develops and maintains documentation of the Medicare Risk, ACA/Marketplace and Medicaid Adjustment processes
- Analyzes and monitors clinical Risk Adjustment reports to and from CMS to assure data accuracy and compliance
- Supports the development of monthly revenue accruals and forecast related to the risk adjustment activities
- Maintain excellent understanding of all CMS and state requirements and directives for Risk Adjustment to ensure process is compliant with these requirements
- Oversees and monitors data submission for attestation to CMS for Risk Adjustment
- Oversees vendor and internal processes for accurate and timely Risk Adjustment Factor calculations across Medicare, ACA/Marketplace and Medicaid lines of business
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions
- Perform any other job duties as requested
Education and Experience:
- Bachelor of Science degree in Finance, Business Administration, or Clinical related field or equivalent work experience is required
- Seven (7) years of experience in analyzing health care claims data and/or risk scores, to include database experience (SAS, SQL, or Access), required
- Three (3) years of management/supervisory experience required
- Experience in communicating and presenting to senior leadership preferred
- Knowledge of health care reporting standards preferred
- Managed care or healthcare experience is preferred
Competencies, Knowledge and Skills:
- Expert proficiency level with Microsoft Excel
- Knowledgeable of Medicare/CMS Risk Adjustment regulations
- Knowledgeable of ICD-10 and CPT codes
- Ability to manage, develop, motivate and reward professional staff
- Ability to effectively report data, analyze facts, and exercise sound business judgment when making recommendations
- Critical listening and thinking skills
- Advanced proficiency with Microsoft Suite to include, Word, Power Point and Outlook
- Ability to work independently and to manage multiple priorities with limited resources
- Ability to analyze problems, draw conclusions, develop processes and communicate status and results
- Excellent oral and written communication skills
- Ability to interact with executive levels of management as well as external stakeholders
Licensure and Certification:
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$113,000.00 - $197,700.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#LI-SD1