Senior Risk Adjustment Analyst – Medicaid Job in Garden City, NY at HealthCare Partners

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HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products.

Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources. HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.

Interested in joining our successful Garden City Team? We are currently seeking a Senior Risk Adjustment Analyst – Medicaid. Position Summary: The position will support revenue program management activities around data management and submissions to NYSDOH.

Serve as a subject matter expert to management and stakeholders around end-to-end process of data management, data processing, data analysis and submissions. Interface with different business areas on the execution of data submissions, identifying and applying best practices and processes to ensure efficiency and accuracy of end-to-end operation of risk adjustment programs. Identify and recommend both strategic and tactical improvements, and contribute to compliance to all applicable laws, guidance, and regulations.

Develop and sustain a long-term optimal structure and processes around emerging encounter data submission requirements; analyzing, monitoring, and planning key risk adjustment milestones and identifying and recommending opportunities for improvement. Assist in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance. Work closely with end-users to gather reporting requirements and analyze internal reporting tools; to ensure proper testing and validation of data elements on the finished product; to participate in the resolution of reporting problems; to build, perform, and maintain reporting analysis and modeling; to provide analytical support on various strategies to ensure organizational goals are met; to propose opportunities in maximizing reimbursement based on the NYSDOH Risk Adjustment model; to propose innovative approaches to create or improve automation and optimize processes data and analytic processes as well as reporting; and to lead cross-functional analytical and operational teams toward the goal of improved risk adjustment scores.

Essential Position Functions/Responsibilities: Data Management & Submissions: Identify, promote and execute program activities around data submission and management to ensure maximum efficiencies, accuracy and completeness. Define strategic and tactical approaches to improve risk adjustment operations across the enterprise to support the underlying workflow of these systems. Oversee the development of requirements, testing and refinement of the underlying data and systems.

Partner with other business units to deliver requirements around necessary updates to underlying data and systems as used by the Risk Adjustment and Coding departments. Recommend, develop, and monitor processes around data collection, submission, and reconciliation to ensure full compliance with all applicable laws, guidance, and regulations. Provide detailed reporting and oversight for data submission activities.

Develop dashboards to report progress with sponsors and escalate issues with key stakeholders. Understand NYSDOH risk score methodology, including risk score calculation, financial risk receivable calculations, APD/OSDS processes and key regulator deadlines for data submission, APD/OSDS Return Files and Error Files, understand eligibility, ICD coding, claims, and provider data. Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are addressed in a timely manner.

Interface with Quality, Finance, IT, Provider, Claims, Business Intelligence, and other HCP teams to improve and correct data. Analyze data flow and data integrity to identify areas for improvement in risk adjusted revenue. Complete routine quality assurance checks to ensure data accuracy and completeness and execute corrections as needed.

Update, create, and maintain business process and technical workflow documents. Analytics, Operational, & Project Management Duties: Operate risk adjustment analytic vendor platforms to assist with intervention tracking, monitoring, analysis and reporting of diagnosis codes that drive risk adjusted payments. Oversee the analysis and interpretation of provider-specific results and risk score trend information; develop dashboard reporting and a regular schedule for delivering the results of analyses to improve awareness and understanding of risk adjustment results and the quality, accuracy and identification of member health conditions.

Assist the Risk Adjustment Director in providing HCP Teams with appropriate tools, resources, and reports to help achieve success with downstream providers. Conduct analyses to develop a comprehensive understanding of a provider’s risk score trends, EMR systems, contracting arrangements, and business models to recommend generate provider-specific engagement plans. Support project management efforts including monitoring and evaluating progress against timelines, project milestones, key deliverables, and resource requirements.

Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support the Risk Adjustment Director in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved. Collaborate across business units to coordinate the development of financial dashboards and models to identify and track revenue and ROI trends.

Work with team members to understand and monitor the financial impact of risk adjustment programs. Contribute to developing materials and presenting key updates to HCP leadership regarding risk adjustment programs and provider and member engagement initiatives. Qualification Requirements: Skills, Knowledge, Abilities Advanced proficiency in SQL (required).

Advanced proficiency in MS Excel (required). Direct experience with and aptitude for using data warehouse/data mart products (required). Direct experience with relational databases and knowledge of query tools, specifically SAS (required).

Ability to manage projects and project plans within stated time lines (required). Ability to communicate effectively, and work well in a team oriented environment (required). Resourceful and creative in solving complex issues and working collaboratively with others (required).

General knowledge of ICD-9/10 codes (optional). Training/Education: Bachelor or Associate degree in Computer Science, Management Information Systems or Health related field (required). Experience: A minimum of 5 years’ experience in managed care or other healthcare environment in an analyst role.

Direct experience with NYSDOH risk adjustment methodology and risk revenue financial analytics (optional). Direct experience with APD/OSDS data submission processes (required). Direct experience utilizing risk adjustment analytic vendor platforms (required).

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Department: Risk Adjustment This is a non-management position This is a full time position