Government Programs Risk Adjustment Analyst

Position Description

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."

This role is responsible for supporting the Risk Adjustment Program with analytics and day-to-day activities impacting the programs strategy and operations. The Risk Adjustment Analyst works closely with the Risk Adjustment & Stars Programs Management leader(s) supporting the execution of the Program strategy through analysis and reporting tactics driving results to improve or maintaining risk adjustment compliance, cost and revenue, submissions process, and operations. The role will include support in the development of reports, enhancement to existing reports, data analysis, processes, and methodologies that will inform and enable the Risk Adjustment leader(s) to make informed decisions based on data and drive the execution of the Program strategy and operations effectiveness.

Responsibilities and Qualifications

• Assist and/or develop new reports or analysis, enhance key existent reports and/or analysis processes, and methodologies of the Risk Adjustment Program operations and initiatives.

• Support the implementation and on-going activities of vendor operations and analytics tools. Vendor management activities such as: contract implementation, delegated activities execution from an analytics standpoint, and performance guarantees monitoring process.

• Develop standardized reporting and controls for vendor's management and performance monitoring process to ensure appropriate and timely data flow between teams.

• Prepare contracts, projects, and/or initiatives performance reports, gap analysis, etc. based on key performance indicators. Communicate performance updates and findings to leadership.

• Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals.

• Data review, monitor and active participant in the completion of submissions for Medicare and Commercial/ACA products (e.g. RAPS/EDPS submissions).

• Utilize analytics to identify trends, opportunities for improvement, and potential Programs development.

• Collaborate with the Risk Adjustment & Stars Programs leader(s) and team to monitor and project year to date and end of year performance.

• Participate on new projects, processes and/or workflows.

• Support the development and implementation of remediation strategies (for internal and/or external business partners).

• Support the development and maintenance of the Risk Adjustment tactics effectiveness. Creation of processes, documentation, and reporting infrastructure.

Skills:

• Creating and applying data to problem solve

• Consistent with delivering results on time and high quality/accuracy.

• Ability to communicate and summarize complex data processes, findings, etc. in a simple and clear way.

• Problem solving and critical thinking mindset that's oriented to find solutions.

Knowledge:

• Financial analytics knowledge with data mining principles: predictive analytics, mapping, collecting and complex manipulating data from multiple data systems.

Experience:

• 3 years of experience in risk adjustment and data analytics.

• Financial analytics knowledge with data mining principles: predictive analytics, mapping, collecting and complex manipulating data from multiple data systems.

• Highly skilled in MS Access, Excel, SAS, SQL, Power BI, and other query/reporting tools.

• Project and/or vendor management experience is a plus.

Education and Certifications:

• Preferred: Bachelors or Master's Degree in Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics, Public Health or Health-related Sciences, or Health Administration.

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.