The Risk Adjustment Analyst - Associate will support the Risk Adjustment and Coding Management department's goals with regard to the Commercial and Medicare risk models. The position will be involved in building, coordinating, and analyzing the impact of various activities used to support risk coding optimization. This would require evaluating and analyzing the effectiveness of prospective and /or retrospective programs, including reviewing claim/member/provider data. The Risk Adjustment Analyst - Associate will need to be able to work effectively with other team members in order to close clinical care reporting and diagnosis coding gaps to ensure complete and accurate capture of revenue, based on the risk adjustment models.
Essential Job Duties:
Participate in submission and monitoring Risk Adjustment Processing System (RAPS), Encounter Data System (EDS) and External Data Gathering Environment (EDGE) to ensure data submitted and reported for Medicare and Affordable Act risk adjustment is complete and accurate.
Perform periodic and ad hoc analysis utilizing complex spreadsheets and systems by developing new and innovative approaches.
Assist with provider education and training on Risk Adjustment methodologies, documentation and coding in an effort to close clinical coding gaps which impact risk score and provide revenue enhancement.
Assist with implementing risk adjustment activities, as a result of regulatory changes to the program.
Provide support on the annual Risk Adjustment Data Validation (RADV) audit in relation to vendor oversight, management status updates, audit preparation and completion.
Assist with the yearly prospective audit to ensure data accuracy and completeness in regards to regulatory requirements within Risk Adjustment.
Serve as a liaison with vendors on all aspects of Risk Adjustment projects for Case Management, revenue capture, compliance and regulatory reporting.
Assist in the development of Risk Adjustment programs based on evaluation of risk adjustable member and provider analytics.
Interpret and analyze claims and membership data in support of Actuarial and Utilization analysis to track trends, identify gaps.
Attend continuing education classes/seminars to maintain professional and technical knowledge to ensure compliance with Federal reporting requirements.
Perform other assignments as needed.
Bachelor Degree or a combination of education/experience in Health Insurance.
Experience analyzing and manipulating large sets of healthcare data (i.e. identifying trends and patterns)
Experience in MS Excel (i.e. recent experience developing pivot tables, v-look ups, formulas, etc.)
Prior presentation experience
Excellent critical thinking skills
Excellent written and verbal communication skills
Self-driven, ability to work independently and facilitate change
Ability to handle multiple key deliverables simultaneously, meet time sensitive deadlines and organize workload with general supervision.
Experience working with CMS, HHS Risk Adjustment methodology, Medicare Managed Care, and Affordable Care ACT.
Medical coding experience (Certified CPC-A, CPC, CCA or CCS through AAPC/AHIMA),
Experience with required data submissions through the various government systems.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same