Risk Adjustment Analyst - Health Plan

at St. Luke's Health System in Boise, Idaho, United States

Job Description

The Risk Adjustment Analyst serves as a strategic partner to the business segments within the St. Luke’s Health Plan. In alignment with identified strategies and tactics, leads the development of business processes and delivery of insights and health insurance data analysis, while working with cross-functional stakeholders.

This role is specifically for a Risk Adjustment Analyst to bring their knowledge, technical skills, and experience in risk adjustment for QHP/ACA and Medicare Advantage to the St. Luke’s Health Plan.

What You Can Expect:

• Analyzes and interprets health insurance data, including eligibility, premium, medical, and pharmacy claims data. Subject matter expert on available health insurance data. A creative problem solver in applying that data to identify, escalate, and resolve operational issues.

• Understands and interprets operational processes and business context to translate technical, clinical, financial, and operational problems into analysis, which yield insights and information to support decision making.

• Expertise with health insurance regulatory programs and requirements, as well as associated data, including HEDIS/quality programs, risk adjustment, and utilization management.

• Performs high value health insurance data analysis, interpretation of key business metrics, and presents insights to business leaders and key stakeholders to aid decision making and operational planning.

• Challenges and supports business decisions with analytical rigor, insights, and judgments to drive better decisions.

• Partners with internal Data & Analytics team to define scope, requirements, data validation, and provide prioritization input on requests and needs. Collaborates with vendors and other external parties to develop data requirements and ensures appropriate data validation and integrity.

• Works with and contributes to data management and data governance to understand and help define data policies and standards to ensure high quality data and analytics.

• Develops and maintains a high degree of functional, analytical, and technical acumen. Builds successful partnerships with key internal customers and cross functional teams.

• Responsible for and performs all but the most complex assignments and work requiring independent judgment and decision making. Serves as a subject matter expert for colleagues in other functions.

• Leads special projects and participates on workgroups and teams, as assigned.

• Completes other duties and responsibilities as assigned.

Qualifications:

• Education: Bachelor’s degree or experience in lieu of degree

• Experience: Six (6) years’ relevant experience

Preferred Qualifications:

• Experience in QHP/ACA and Medicare Advantage Risk Adjustment Analytics

• Experience in MA Encounter Data Submission

• Experience in EDGE Server Data Submission

• Strong skills in SQL

• Knowledge of HEDIS and Stars a plus

At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.