• Risk Adjustment Technical Analyst

    Job Locations US-RI-Smithfield
    Req No.
    Medical Expense Management
    Regular Full-Time
  • Overview

    The Risk Adjustment Technical Analyst position supports, compiles and reports key information created, enhances and maintains for reporting, budget or financial models, or benchmarks for an Accountable Care Act or Medicare Risk Adjustment as prescribed by Center for Medicare and  Medicaid Services, Department of  Health, Health and Human Services or other State and Federal Regulatory Agencies. This position will function in conducting and manage outcome of various data points that may include, analyzing, reviewing, forecasting, and trending of data to support health plan Risk Adjustment Financial Strategy.


    Program Management:

    • Strong acumen for analyzing, data mining, and reporting related to Medicare and Exchange Risk Adjustment Programs.
    • Ability to support strategic direction for program operations, goals, metrics, tasks, timeframe and appropriate reporting and timing related to all National HCC Activities.
    • Identify and apply best practices to ensure accuracy of risk adjustment submission, response and reconciliation in all markets served by Neighborhood Health Plan
    • Reconcile data to outcomes, Risk Scores and Trending patterns to project future payment or Risk Adjustment Factors Scores
    • Monitor risk adjustment relates activities including but not limited to risk adjustment program payments, encounter data submission and return files to ensure all tasks are completed in a timely manner and achieve expected outcomes
    • Develop tools to be used to improve accuracy of coding and documentation that meet State and National Standards
    • Consistently exhibit behaviors and foster relationships with peers and internal stakeholders

    Data Submission:

    • Ability to analyze and report out to ensure timely, accurate and complete submission of risk adjustment data to CMS and ensure reconciliation of Plan Payment, Estimated Medical Loss Ratio and Rebate Requirements
    • Validate compliance with resubmissions, error correction, alternative methods of data submission and data file layouts
    • Creating visual modeling or diagramming of the current and proposed work flow designs that will assist other internal and external stakeholders on the process/business flows associated with Risk Adjustment Processes and Analytics

    Regulatory Oversight and Quality Assurance:

    • Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
    • Support strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.

    Provider Engagement, Training and Support

    • In Partnership with Manager, support internal departments in financial analysis, on error rates associated with coding accuracy to ensure data is complete and accurate prior to submission to external agencies.
    • In conjunction with other departments, develop and implement programs that will enhance provider training and education of the HCC Risk Adjustment Process, Proper Medical Record Documentation and Diagnosis Accuracy.

    Analysis and Use of Results

    • Support and document analysis of risk adjustment programs including ROI, productivity, quality, risk score/ revenue impact at the plan and provider group level.
    • Utilize analysis to identify trends and opportunities for improvement, new strategies and further program development
    • Support Manager with Medical Management on the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.
    • Collaborate with Manager to project and monitor the impact of coding programs on CMS revenue for budgets and plans

    Enterprise Risk Adjustment

    • Support Manager in driving enterprise-wide risk adjustment initiatives.



    • 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

    Organizational Competencies:

    • 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

    FDR Oversight:

    • 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

    Travel Expectations:

    • Local Business Travel


    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.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org.


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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