- Bachelor Degree in Information Technology, Business or Finance
- 2-3 years’ experience in Health Plan Operations to include Risk Adjustment Activities
- Experience and strong participation with a Risk Adjustment Team as the primary point of contact between the technical teams and Design or Product Management
- Experience translating business and design requirements into technical requirements for Risk Adjustment as outlined by CMS or other State Regulatory Requirements
- Experience in critical analysis on information from multiple sources, identify issues and break down high-level information into detailed workable requirements.
- Serve as a resource between IT and all Operational Business Units to include Risk Adjustment, Finance and other departments that may need understanding of the overall Technical aspect of the Risk Adjustment submission and reporting process.
- Previous experience in risk adjustment activities in a Medicare, Accountable Care Act or provider organization to including submission of RAPs, and EDPS, EDGE Server files submission, responses and reconciliation per CMS and other State and Federal Guidelines.
- Experience with business and technical requirements of all inbound and outbound data associated with a strong Risk Adjustment Business Unit.
- Strong knowledge base of data points associated with the end to end process of plan payment
- Experience in gathering requirements and focused understanding of complex solutions
- Knowledge of claims coding and payment methodology, associated with a Health Plan domain.
- Advanced analytical problem solving skills
- Advanced skills with Microsoft Office (Project, Word, Excel, PowerPoint, Outlook)
- Strong background in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) Methodologies
- Experience in Project Management, Statistical Methodologies and Analysis
- Advanced Degree or Certifications in related field
- System application or SQL capabilities
- Judgment and Decision Making
- Gets Results
- Collaboration and Teamwork
- Business Awareness
- Customer Focus
Job Specific Competencies:
- Attention to Detail
- Creativity & Innovation
- Relationship Building & Networking
- Continuous Quality Improvement
- Planning & Organization
- Business Lead Level:
- In the role of business lead for assigned FDR; incumbent is responsible to complete comprehensive oversight and monitoring of their vendor that incorporates the following elements: efficient and effective operations; compliance with laws, regulations, policies, procedures; and other company performance issues designed to reduce risk and add value to the company
Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.
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Neighborhood is an EOE M/F/D/V and an E-Verify Employer