Under the supervision of the Manager, Data and Reporting, this individual will be responsible for supporting critical data submission functions for the Risk Adjustment Department (RAD) including risk adjustment submissions to CMS, internal data reconciliations, data transfer between Point32Health and external stakeholders such as vendors and provider organizations. This individual will have strong analytical skills and the ability to synthesize large data sets and complex information into key insights. This individual will work effectively across business areas and often lead collaborative projects. This person will need to follow complex business processes, consider options when problems arise, and to identify and escalate issues appropriately.
Key Responsibilities/Duties – what you will be doing
Data Submission Integrity
- Support Medicare Advantage manager across a range of activities, including monthly encounter data submission to CMS, and other States or Federal agencies
- Monitor ongoing encounter data response files to identify and address discrepancies in a timely manner
- Review monthly error reports, perform trend analysis, investigate critical errors and work with the appropriate business area on resolution
- Enhance and automate existing reconciliation and reporting code using advanced SAS skills
- Interface with IT for implementation of enhancements and timely resolution of production issues pertaining to CMS and risk adjustment data submission, including issue investigation, business requirements, user acceptance testing and post implementation monitoring
Reporting and Data Management
- Use Tableau/Cognos/Excel to maintain and enhance monthly submission dashboard and run submission reconciliations to effectively track acceptance rates and submission trends
- Creating various reconciliations reports and ad hoc reporting
- Use SAS/Alteryx to extract and transform data to create reports from multiple sources
- Assist with the implementation of new programs, including data file transfers and reviews of internally received files for completeness, reasonability, and accuracy
Collaboration with Internal / External Stakeholders
- Collaborate effectively with risk adjustment leadership and with other internal stakeholders including Claims, Member Operations, Information Technology and Provider Information to ensure that process enhancements and submission mechanisms are maintained and monitored
- Collaborate with federal agencies, vendor data management staff, and industry trade associations to remain up to date with changes and updates from CMS. Effectively communicate regulatory updates to team and department leadership, escalate risks appropriately
Analytics
- Conduct ad hoc analyses specific to risk score trends, data/claims submissions and program performance to support risk adjustment analytics
- Perform data analytics to support ongoing and upcoming risk adjustment initiatives
Administration
- Support the creation and management of business policies and procedures and knowledge repositories for the department as needed
Qualifications – what you need to perform the job
EDUCATION, CERTIFICATION AND LICENSURE:
- Bachelor’s degree required, background in health informatics, business analysis programming, IT, finance, quantitative techniques, or a related discipline.
EXPERIENCE (minimum years required):
- 3-5 years of experience in progressively responsible analytical data management roles in a complex operational setting or consulting role.
- Previous experience working in the healthcare / health insurance sector either for a health plan, provider group, healthcare IT / management consultancy or auditing firm and/or experience working with large data sets in a technical capacity.
- Understanding of claims systems, provider information, and Medicaid/Medicare preferred.
SKILL REQUIREMENTS:
- Expertise in data management and controls, IT processes, and utilizing analytical tools. Comfortable working with large data sets from disparate sources, and able to identify relevant patterns and trends
- Expertise in SAS Enterprise Guide/ SAS Base and SQL (SAS certification preferred)
- Experience with database software and reporting tools such as SQL Server, Oracle, and Cognos
- Experience with Alteryx, Cloudera, Tableau, and knowledge of X12 837, 277, 834, 820 EDI a plus
- Proficient in Microsoft Excel, PowerPoint, and Word
- Experience developing and updating detailed documentation of policies and procedures
- Engaged, critical thinker, organized, detail-oriented, resourceful, and self-motivated
- Must possess maturity, a high degree of professionalism and be able to deal with complexity and uncertainty and/or business decision ambiguity in the face of incomplete information
- Strong interpersonal and communication skills with an ability to work collaboratively with both internal and external stakeholders
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS
- Must be able to work under normal office conditions and work from home as required. Must be able to work in office one day per week.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
Commitment to Diversity, Equity & Inclusion
Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities.
This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.
Req ID: R7802
