Risk Adjustment Specialist Senior

It's more than a career, it's a calling.WI-Dean Health Plan 1277 DemingWorker Type:RegularJob Summary:Plans and leads activities and assists in the development and evaluation of Medicare and Commercial Affordable Care Act (ACA) annual risk adjustment strategies. Formulates fact-based decisions and implements initiatives, programs and process improvements through prospective and retrospective analysis of claim/member/provider data. Partners with providers and clinical operations staff to optimize diagnosis coding and documentation to ensure complete and accurate capture of disease severity of membership, based on the risk adjustment models. Collaborates with other SSM departments relating to data impacting government reporting.Job Responsibilities and Requirements:PRIMARY RESPONSIBILITIESDesign, execute and implement new risk adjustment strategies, programs, and initiatives as directed by management. Propose changes to new and existing initiatives to achieve improvement and revenue optimization. That include provider and member engagement, prospective and retrospective reviews for multi-state Medicare and Commercial ACA risk adjusted products.Cultivate and foster impactful network relationships. Lead extensive collaboration with providers, clinic managers, and medical coding staff to close diagnosis coding gaps identified by various sources. Develop and disseminate monthly reports that includes implementing and evaluating provider feedback, and identifying clinical and provider processes for diagnosis capture improvement. Request and/or review medical records for prospective and retrospective review, to improve completeness and accuracy of data submission to the government.Develop, initiate, and provide clinical staff and provider's education and training on Risk Adjustment methodologies, documentation and coding in an effort to capture complete and accurate disease severity to optimize revenue. Identify and share best practices with clinics to improve performance related to risk adjustment initiatives.Lead and/or participate in multi-disciplinary improvement teams within SSM and system-wide to provide subject matter expertise on risk adjustment. Represent SSM Risk Adjustment team in meetings with other health plans, performance improvement groups, regulatory bodies, and internal work teams.Develop and implement key interventional strategies to improve overall risk adjustment; aligning and augmenting efforts across programs and systems as appropriate (Quality Improvement Program and Value Contracting).Interpret and analyze claims, provider and membership data in support of actuarial and vendor reporting and utilization analysis to track trends, identify gaps to reduce government reporting risk and ensure maximum revenue capture.Analyze and evaluate results of risk adjustment strategies, programs, and initiatives; prepare and present reports and findings to various audiences; and, identify potential solutions to positively impact key opportunities for improvement. Annually evaluate risk adjustment program effectiveness as required by Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services (HHS) and other regulatory bodies.Work directly on the annual Risk Adjustment Data Validation (RADV) audit in relation to vendor oversight, management status updates, audit preparation and completion. Execute results of a yearly prospective audit to ensure data accuracy and completeness in regards to regulatory requirements within Risk Adjustment.Monitor and perform quality checks of Risk Adjustment Processing System (RAPS), Encounter Data System (EDS) and External Data Gathering Environment (EDGE) to ensure data submitted and reported to Medicare and Affordable Act risk adjustment is complete and accurate.Monitor, interpret, and provide regulatory changes/updates that may impact Risk Adjustment operations. Maintain current knowledge of CMS and/or HHS Risk Adjustment methodology, Medicare Managed Care, and Affordable Care Act using and monitoring Registration for Technical Assistance Portal (REGTAP), CMS, and HHS websites; along with attending conferences and educational presentations/seminars.Perform other duties as assigned.EDUCATIONBachelor's degree, or equivalent combination of health insurance experience and educationEXPERIENCEThree years' experience in Medicare and/or Commercial ACA risk adjustment in a health plan or integrated delivery system.PHYSICAL REQUIREMENTSFrequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.Frequent keyboard use/data entry.Occasional bending, stooping, kneeling, squatting, twisting and gripping.Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.Rare climbing.Work Shift:Day Shift (United States of America)Job Type:EmployeeDepartment:97100### ####19-Actuary and Risk Adjustment -GovernScheduled Weekly Hours:40SSM Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.Learn more here