Job Summary: This position focuses on all CMS submission related operations in support of Prominence Health Plan's Medicare Advantage business. Activities include creating submission files related to chart retrievals per vendor proprietary format, perform data analysis in support of optimizing risk adjusted revenue, maintain compliance with all CMS standards related to health plan submissions, and modeling the financial impacts of changes in risk adjustment data and methodologies. This position will work with multiple internal departments, maintaining tracking documentation to ensure closure of gaps and resolution of data errors. Assist in reporting current KPIs and create new reports to appropriately track ROIs.

Job Duties/Responsibilities:

• Performs data services and analytics to improve risk adjusted revenue while remaining in compliance with CMS standards; develops financial impact models of changes in risk adjustment data and methodologies
• Responsible for planning, developing, and organizing meetings surrounding claims and enrollment data submission and error resolutions. Documents meeting notes and project statuses and workflow processes.
• Documents workflow. Identifies areas at risk/barriers. Collaborates with other departments to create remedies. Makes recommendations for changing or developing new processes.
• Creates submission files related to chart retrievals per vendor proprietary format, perform data analysis in support of optimizing risk adjusted revenue, maintain compliance with all CMS standards related to health plan submissions, and modeling the financial impacts of changes in risk adjustment data and methodologies.
• Acts as subject matter expert in Risk adjustment Medicare Advantage and Commercial data submission and CMS timelines. Makes recommendations to manager regarding business decisions as per industry standards.
• Collaborate with internal departments e.g., Finance, Operations, Network Management, Provider Contracting, and Health Management and external vendors on risk adjustment projects. Calculate the ROI for risk adjustment vendors, initiatives, and projects.
• Interprets response files from CMS and takes necessary action to track and resolve the errors.
• Build reports to track risk adjustment related projects and track the effectiveness of the initiatives; identify and resolve gaps or errors in data
• Develops regular and ad hoc reports to supplement risk adjustment processes through query building and data extraction, including monthly risk adjustment revenue accruals.
• Collaborates with cross-functional departments to provide insights into the current state of operations and identify gaps and opportunities for improvement.
• Performs data mining functions and identifies trends in data. Informs leadership of findings and collaborates to create predictive models using information obtained from mining.
• Assist in the submission and creation of the supplemental records, claims, and enrollment files to the vendor in their proprietary format.
• Collaborate and track multiple projects with multiple clients and internal teams simultaneously to ensure quality data is being submitted to CMS for Risk adjustment.
• Assist in reporting current KPIs and create new reports to appropriately track ROIs.
• Write intermediate SQL queries to respond to requests including drill down analyses to identify specific opportunities for cost and quality improvement
• Collaborates with internal departments, maintaining tracking documentation to ensure closure of gaps and resolution of data errors.
• Participates in special projects and performs related duties as assigned.

Requirements:

• Bachelor's Degree in Health Care Administration, Business Administration, or a related field
• 3 years' experience in data analysis and reporting preferably in healthcare domain.
• Strong Project management, active PMP certification preferred
• Intermediate/advanced experience with SQL and the ability to write SQL queries and perform table joins, and complex data merges
• Working knowledge of Commercial Risk adjustment and EDGE server.
• Proficient in Excel (pivot tables, macros), PowerPoint, Word, Visio, Outlook, SharePoint.
• Working understanding of various Medicare Advantage risk adjustment models (RAPS and EDPS) and maintains current knowledge of CMS' Hierarchical Condition Categories (HCC) and claims submission to CMS.
• Adept critical-thinking and analytical problem-solving skills
• Excellent statistical skills with ability to evaluate and analyze data.
• Highly organized with strong planning skills along with documentation of workflow process.
• Ability to work independently and on a team in a fast-paced environment with increasing levels of work responsibilities
• Committed self-starter with a demonstrated history of strong work ethic and reliable task completion and leading multiple projects from start to finish along with appropriate documentation.