About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief summary of purpose:
The primary role of the Sr. Risk Adjustment Analyst will be to function as the Claims SME for the Risk Adjustment & Analytics Department. The Sr. RAA implements data analytic reports, as well as analyzes and researches data errors and issues, collaborating with internal departments to work toward error resolution and risk outcome improvement. The Sr. RAA will own the claims adjustment workflow associated with regulatory retrospective chart review efforts.
The Sr. Risk Adjustment Analyst will have shared ownership within the Analytics staff for product line(s) as assigned by the Sr. Director, and will be a SME for the respective risk adjustment model(s) and related data submission requirements. This role will be familiar with all revenue streams relevant to the product line(s) and will develop reporting to enhance understanding of Fallon's risk scores over time and to improve revenue accuracy. The Sr. RAA will review and apply all related regulatory requirements to department activities, i.e. audits, changes in rate models, changes in submissions, etc. The Sr. RAA will also work with the Government Programs Actuary, product line management, Medical Economics and Care Services to provide analysis and recommendations to improve product performance.
The Sr. RAA will support development and implementation of targeted member listings for chart reviews, in home assessments and outreach efforts across Fallon's product lines. The Sr. RAA will run commercial and other risk adjustment models and will work with IT to provide accurate data to external consultants for statewide commercial risk adjustment simulations. The Sr. RAA will also manage the Medicare PDE and DIR processes and review invoices for external vendors.
The Sr. Risk Adjustment Analyst will interface with external and internal customers and vendors to identify and/or analyze business problems and develop solutions, as well as improve workflows and business processes to optimize Risk Adjustment results.
The Sr. RAA will represent the Risk Adjustment & Analytics team, participating in corporate project workgroups and team initiatives as assigned. The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed.
Optimize risk adjustment data submissions
Claims SME for assigned population
Analyze, prioritize & support resolution of Claims/ Encounter data errors
Support targeting and selection of optimal populations for chart review and in home assessments
Coordinate accurate delivery of chart review findings for claims adjustment process
Support/enhance risk score monthly reporting
Product Line support
Educate product line management on drivers of variances from budget for all revenue streams
Meet regularly with product line management to identify and implement reports to improve product performance and identify opportunities to enhance revenue
Commercial risk adjustment support
Support accurate and timely data submission to CMS EDGE server
Develop targeted member lists for outreach efforts
Provide member level risk score data to support production of risk-adjusted P&L reporting
Act as liaison with external consultant for risk adjustment simulations
Manage PDE and other processes
Handle PDE response files and work with PBM on PDE error resolution
Provide updates for regulatory reporting dashboards
Manage review of invoices for external risk adjustment vendors
Corporate Project support
Fallon Community Health Plan