The Risk Adjustment Analyst performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS and NYS standards and modeling financial impacts of changes in risk adjustment data and methodologies. Interacts with internal departments such as Finance, Medicare Operations, Network Management, Provider Contracting, Health Informatics, and Marketing & Sales. Also interacts with vendors on risk adjustment projects. Higher level positions will also interact with external agencies like BCBSA, AHIP, NYS DFS and CMS as well as external vendors and outside actuarial consultants. Develops financial projections and conducts analysis for risk adjustment projects including retrospective chart review and prospective initiatives. Primarily using SAS, the Risk Adjustment Analyst gathers, standardizes and consolidates financial claims, membership and premium data into SAS data sets that are used for risk adjustment analytical and reporting needs. Analyst should leverage industry resources to increase knowledge and improve ROI of risk adjustment activities.
• Maintains current knowledge of risk adjustment models such as: CMS’ Hierarchical Condition Categories (HCC) and RxHCCs, HHS HCCs and Clinical Risk Groups (CRGs) along with other open source and third party models.
• Responsible for encounter data collection, processing and reconciliation; including identification of trends.
• Supports pricing work through estimation of risk scores and associated revenue.
• Develops monthly risk adjustment revenue accruals.
• Participates in regulatory/external party audits.
• Calculates ROI for risk adjustment vendors, initiatives and projects.
• Supports analysis of regulatory changes in determination of the Health Plan impact.
• Assists in the preparation of risk adjustment analyses.
• Supports higher level analysts on special projects involving other areas of the company.
• Assists in performing analyses used in the development of financial plans, re-forecasts, and other financial projections.
• Assists in efforts to continually improve data capabilities and quality of department analysis and reporting.
• Develops ad hoc reports to supplement risk adjustment processes through query building and data extraction.
• Highlights downstream impacts of data/system changes (ICD-10 transition, etc.).
• Assists in the development of risk scores in support of pricing and forecasting.
• Supports risk sharing analyses, capitation development, and associated settlements.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Supports RADV analytics
• Works error reports for Encounter Data submissions to CMS.
• Maintains SOX controls related to financial reporting of risk adjusted revenue.
In addition to Level I responsibilities:
• Shares knowledge with newer department employees.
• Assists in the development of risk adjustment analyses concerning complex issues and trends, coordinates with staff.
• Works with outside vendors during implementation and maintenance of key projects.
• Identifies and develops corrective action with regards to Data Warehouse integrity issues.
• Reconciles Data Warehouse data with corporate financials.
• Initiates and leads efforts to continually improve data capabilities and quality of department analysis and reporting.
• Draws together facts and input from a variety of sources.
• Accountable for loading monthly data marts, updating hand-managed tables, and maintaining code that generates the information contained in those data marts and tables.
• Provides decision support in the form of advanced statistical analysis/business intelligence (Forecasting, Data Mining, OLAP)
• Performs advanced programming and statistical analysis/support for ad hoc requests.
• Proposes and assists in development of risk adjustment process improvements and automation of processes utilizing SAS software.
• Participates in on-going training for analytic and business intelligence tools (especially SAS and VBA).
In addition to Level II responsibilities:
• Develops risk scores for rate filings. Maintains methods and models or formulas for Medicare lines of business.
• Develops risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff.
• Manages projects; including development of project plans, tracking and reporting the status of projects, coordination/leading of meetings and presentation of results to management.
• Provides effective technical advice and support to assist management in meeting corporate goals and identifying strategy. Involves other departmental areas as needed.
• Trains new SAS users and/or works with existing users to transition work over to SAS or improve the performance of current SAS programs/projects.
• Develops and reviews policies and procedures for risk score processing and error resolution.
In addition to Level III responsibilities:
• Recommends departmental annual performance goals.
• Leads risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff.
• Interprets how regulatory changes affect Health Plan and develops impact analyses.
• Provides support to assist management in meeting corporate goals and strategic decision making.
• Provides decision support and performs data mining functions to identify trends in the data.
• Interacts with Actuarial leadership to create predictive models using information obtained from mining.
• Works with new SAS users in other departments to provide introductory training and support using the suite of SAS tools.
• Assesses need and opportunity for upgrades to existing or new SAS products.
• Proposes new SOX control designs to management as needed.
• BS in Math, Economics, Actuarial Science or allied field, minimum one year actuarial or related experience required or in lieu of experience, at least one actuarial exam is required.
• Exceptional analytical skills, with strong verbal and written communication skills.
• Strong organizational skills and ability to prioritize, multitask, and work in fast paced environment.
• A strong understanding of health insurance & health insurance products, managed care, accounting principles, the competitive market, the legislative environment, and any regulatory issue affecting the Health Plan is expected to be acquired.
• Focused on meeting the expectations and requirements of both internal and external customers.
• Good self-motivation, initiative, and an ability to perform under pressure with little supervision.
• Strong PC/programming skills including Microsoft Excel, Access, Word, PowerPoint, VBA, SQL, Power Play and Impromptu and moderate proficiency in SAS required.
• Experience with base SAS programming and/or SQL.
• Desire to participate in the Actuarial Study Program, SAS Certification Program or related career path preferred.
• Understanding of basic principles and design of data warehousing.
• Familiarity with medical claims and medical terminology preferred.
• SAS data integration and predictive modeling experience.
In addition to Level I qualifications:
• A minimum of :
o Three years actuarial or related insurance industry experience required or
o Two years actuarial or related insurance industry experience and two actuarial exams is required.
• Highly proficient computer skills including Excel, Word, SAS, Cognos, PowerPoint and Intermediate SAS programming proficiency.
• High level understanding of non-Actuarial functions such as Rating, Underwriting, Accounting, Provider Contracting, Network Management, Product Development, Medical Management, etc., and how they impact Health Plan operations and financials.
• SAS Certification I preferred.
• 2 years of experience with base SAS programming and/or SQL.
In addition to Level II qualifications:
• A minimum of :
o Six years actuarial or related insurance industry experience required or
o Three years actuarial or related insurance industry experience and four actuarial exams or SAS Certification I.
• Strong ability to recognize and automate repetitive tasks.
• Ability to perform complex modeling independently.
• Advanced SAS programming proficiency and experience with SAS EBI suite – Information Maps, Stored Processes, Web Report Studio, and Information Delivery Portal.
• Project Management/Process Improvement knowledge preferred.
In addition to Level III qualifications:
• A minimum of :
o Ten years actuarial or related insurance industry experience required or
o Four years actuarial or related insurance industry experience in conjunction with ASA & MAAA credentials or SAS expertise and experience with data mining and forecasting.
• A strong understanding of non-Actuarial functions such as Care Management, Accounting, Provider Contracting, Network Management, Product Development, etc., and how they impact Health Plan operations and financials.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer