Healthcare Claims Risk Adjustment Analyst - Hybrid Remote - Fallon Health

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose: 

The primary role of the Risk Adjustment Analyst (RAA) will be to function as the Claims SME for the Risk Adjustment & Analytics Department. The RAA implements data analytic reports, as well as analyzes and researches data errors and issues, collaborating with internal departments to work toward error resolution and risk outcome improvement. The RAA will own the claims adjustment workflow associated with regulatory retrospective chart review efforts.

The RAA will have shared ownership within the Analytics staff for product line(s) as assigned by the Risk Adjustment Operations and Analytics Manager and will be a SME for the risk adjustment model(s) and related data submission requirements. 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 RAA will review and apply all related regulatory requirements to department activities, i.e. audits, changes in rate models, changes in submissions, etc.

The RAA will be responsible for the monitoring and management of the end-to-end data follow of data submissions to vendors and government agencies to mitigate data leakage.

The position will also be responsible for the direction and completion of other ad-hoc projects; including data oversight and analyses as needed. The RAA must be a team player with great problem-solving skills and the ability to prioritize deadlines as appropriate.

Primary Job Responsibilities: 

• Analyze, prioritize & support resolution of Claims/ Encounter data errors by triaging to the appropriate internal departments for a resolution, and/or work with encounter submissions vendor for resolution
• Work with the Senior Risk Adjustment Analyst on monthly operational and performance reporting and dashboards
• Monitor and manage end-to-end data submissions to vendors and government agencies for assigned populations to mitigate data leakage and/or submission errors.
• Cross-train to handle similar tasks across all lines of business

Education:

BA or BS – Mathematics, Finance, Economics, Management, other

Experience:

• Strong claims processing skill, understanding of medical terminology, and familiarity with medical records
• • Intermediate to Advanced skill level with Microsoft Excel, Access and Power Point.
• • Basic Data Warehouse knowledge and experience with Microsoft SQL
• • Strong communication and strong written skills
• • Working knowledge of the provider-based healthcare industry, claims processing, provider billing or Risk Adjustment strongly preferred
• • Familiarity with MassHealth/Medicaid a plus
• • Experience with SAS is plus.

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.

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