Risk Adjustment Analyst II

Job Summary:

The Risk Adjustment Analyst II provides analysis, extracts, review and reporting of data to ensure accuracy and completeness and identify areas of risk and opportunity.

Essential Functions:

• Compile and analyze member information to ensure the Risk Adjustment Factor accurately reflects the member health profile, financial and clinical information.
• Prepare and review integrated analysis and reports to ensure the accuracy and completeness of the Medicare Risk Adjustment data, and to ensure compliance with all CMS regulations and guidelines
• Identifies trends and patterns within the Risk Adjustment data and medical record coding to segment and identify areas of risk and opportunity for additional medical record review, member and provider intervention.
• Analyze actual versus expected MRA results to identify better targeting and projection strategies to reduce risk and improve revenue position of the company.
• Provide management with analysis based on an understanding of the financial impacts of decisions pertaining to Exchange and Medicare Risk Adjustment and revenue.
• Assist in development of membership revenue projections, forecast and budget based on member risk adjustment score and monitoring of variances to identify trends
• Assist in preparation and implement of necessary internal controls for related entities consistent with CMS and to support RADV or other regulatory audits.
• Perform any other job related instructions as requested

Education and Experience:

• Bachelor of Science/Arts Degree in accounting, finance, economics, computer sciences or related field or equivalent work experience is required
• Experience in analyzing health risk scores
• Two to Four (2-4) years of experience in Medical Coding, Risk Adjustment or Finance
• Managed Care or healthcare experience is preferred

Competencies, Knowledge and Skills:

• Advanced proficiency level with Microsoft Excel, advanced proficiency with Microsoft Power Point
• Familiar with a variety of analysis concepts, practices and procedures
• Knowledgeable of Medicare/CMS
• Knowledgeable of ICD-9/ICD-10 and CPT codes
• Wide degree of creativity and latitude (independent judgment) is required
• Ability to work with others and work independently
• Demonstrates analytical/problem solving skills to perform a variety of complicated tasks
• Possesses critical thinking/listening skills
• Ability to communicate with all levels of management
• Detail oriented
• Knowledge of basic to intermediate SQL, SAS or other relational database software is required.
• Business intelligence (BI) tools is preferred but not required

Licensure and Certification:

• AAPC or AHIMA coding certification is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to travel less than 10% of the time

Compensation Range:

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):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business