Senior Risk Adjustment Analyst – Invest in your Future @ Fallonhealth! Remote Position!

US-MA-Worcester

Job ID: 6704
Type: Full Time
# of Openings: 1
Category: Finance
Fallon Health – Corp HQ

Overview

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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 Sr. Risk Adjustment Analyst (RAA) will be a SME for EDPS and RAPS submission data requirements and a strong understanding of the related risk adjustment models. 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 Actuarial Risk Revenue team, 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. 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.

Responsibilities

Optimize risk adjustment data submissions

• Manage & monitor departmental operations and performance dashboards and make recommendations to department leadership
• Manage & monitor provider dashboard and make recommendations for performance improvement
• Ensuring integrity of risk adjustment programs through complete and timely encounter submissions
• Analyzing enrollment and claims data to monitor member engagement and identify opportunities for improved coding and documentation
• Routinely monitor eligibility flag status (e.g., End Stage Renal Disease) analysis to ensure members are in the right revenue designation
• Compile and submit claims adjustment from internal, external and provider group coding initiatives
• Manage CMS and other governmental files intake and distribution

Qualifications

Education:

• BA or BS – Business Administration, Finance, Economics, Healthcare Administration, Mathematics other

Experience:

• Experience in Medicare Advantage Risk Adjustment, other Risk Adjustment Models is a plus
• Support role: Actuarial, Finance, Accounting, Regulatory, Enrollment, Claims – other
• Advanced Excel skills
• SAS
• SQL- Navigator and/or Alteryx experience
• Ability to work independently with strong analytical skills and attention to detail.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

JT18