Veradigm Payer

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

Job Summary

The Senior 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.

Essential Functions

• 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.

Job Requirements

• Bachelor’s degree in actuarial science, Math, Statistics, or in a related field of study
• 3 to 5 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 and experience with 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.

Compliance

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.

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