Expert Risk Adjustment Data Analyst - REMOTE
Welcome to Veradigm! Our Mission is to be the most trusted provider of innovative solutions that empower all stakeholders across the healthcare continuum to deliver world-class outcomes. Our Vision is a Connected Community of Health that spans continents and borders. With the largest community of clients in healthcare, Veradigm is able to deliver an integrated platform of clinical, financial, connectivity and information solutions to facilitate enhanced collaboration and exchange of critical patient information.
Veradigm understands that managed care organizations, pharmacy benefit managers (PBMs), insurance companies, health plans, and other payers need to balance controlling costs with the goal of providing the highest quality of care and optimizing health outcomes for their members.
Solutions from Veradigm Payers:
- Deliver insights to drive quality outcomes cost-effectively
- Improve efficiency for themselves, their providers, and their members through high-speed clinical data exchange
- Impact point-of-care decision making positively by integrating payer guidance and prior authorization management directly in each healthcare provider’s existing workflow
The Expert Risk Adjustment Analyst will assist our organization as a subject-matter-expert in Medicare Advantage and Affordable Care Act (ACA) Risk Adjustment by developing requirements for new analytics and data products, creating customer financial calculations and projections, and researching customer questions regarding their risk adjustment performance.
- Develop business cases and requirements for new products and current product enhancements that will benefit our customers risk adjustment goals.
- Lead customer requests for ad hoc reporting or research.
- Own customer financial improvement modeling (examples include: Mid Year Payment, Final Year Payment, Transfer Payment).
- Lead research initiatives to monitor our internal algorithm performance over time and recommend future enhancements.
- Collaborate with clinicians in outcomes, algorithm performance, and new product development.
- Provide training and guidance to internal and external customers on all facets of the Risk Adjustment process, from initial data capture at point-of-care, through acceptance to CMS, and successfully validated through audit.
- Research and maintain awareness of CMS regulatory guidance and changes, providing expert interpretation for impacts to products and customers.
- Bachelor’s degree in actuarial science, Math, Statistics, or in a related field of study
- 5 to 7 years of experience analyzing and interpreting Medicare Advantage or Affordable Care Act Risk Adjustment data
- Experience supporting the development of scalable analytic and reporting solutions
- Up to 10% travel may be required
Knowledge, Skills and Abilities
- Extensive experience in healthcare industry, with a focus on Risk Adjustment
- Experience with MA/ACA Risk Scoring methodology, including familiarity with condition categories (HCC)
- Experience with actuarial or financial modeling concepts
- Experience interacting with large amounts of healthcare data; directly with the following CMS files (MMR, MOR, MAO-004, MAO-002, EDGE RARSD, EDGE RATEE)
- Experience working with clinical classification such as diagnoses (ICD), procedures (HCPCS, CPT) and claims processing
- Experience working with data to and from submission systems (RAPS, EDPS, Edge), including background on filtering logic for each system
- Experience with MA mid-year and final year projections (MYRA, FYRA) and/or ACA transfer payments
- Advance knowledge of SAS, SQL
- Working knowledge of statistics with ability/interest to become proficient
- Proven technical, analytical, detail oriented, and problem solving
- Strong written and verbal communication
- Professional and interpersonal
- Self-initiative and leadership
- Ability to work within a team environment
- Ability to interface with both external and internal personnel at all levels
- Experience with Snowflake
Job responsibilities include fostering the Company’s compliance with all applicable laws and regulations, adherence to the Code of Conduct and Compliance Program requirements, policies and procedures. Compliance is everyone’s responsibility.
In compliance with the Equal Pay for Equal Work Act we are disclosing the compensation range for roles that could be performed in the required city/states (California, Colorado, New York City and Washington State).
Actual compensation offer to candidate may vary from posted hiring range based upon geographic location, work experience, education, skill level and/or internal equity.
The pay ratio between base pay and target incentive (if applicable) will be finalized at offer.
We strongly advocate that our associates receive all CDC recommended vaccinations in prevention of COVID-19.
Visa Sponsorship is not offered for this position.
Veradigm’ policy is to provide equal employment opportunity and affirmative action in all of its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity or expression or any other legally protected category. Applicants for North American based positions with Veradigm must be legally authorized to work in the United States. Verification of employment eligibility will be required as a condition of hire. Veradigm is proud to be an equal opportunity workplace dedicated to pursing and hiring a diverse and inclusive workforce.
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