Risk Adjustment Analyst III (Remote)

Job Summary:

The Risk Adjustment Analyst III is responsible for compiling and analyzing member information (via SQL/Azure Databrick) to ensure the Risk Adjustment Factor accurately reflects the member health profile, financial and clinical information.

Essential Functions:

• Compile and analyze member information to ensure the Risk Adjustment Factor accurately reflects the member health profile, financial and clinical information
• Prepare and review integrated analysis and reports to ensure the accuracy and completeness of the Medicare Risk Adjustment data, and to ensure compliance with all CMS regulations and guidelines
• Identifies trends and patterns within the Risk Adjustment data and medical record coding to segment and identify areas of risk and opportunity for additional medical record review, member and provider intervention
• Analyze actual versus expected MRA results to identify better targeting and projection strategies to reduce risk and improve revenue position of the company
• Provide management with analysis based on an understanding of the financial impacts of decisions pertaining to Exchange and Medicare Risk Adjustment and revenue
• Responsible for the development of membership revenue projections, forecast and budget based on member risk adjustment score and monitoring of variances to identify trends
• Assist in preparation and implement of necessary internal controls for related entities consistent with CMS and to support RADV or other regulatory audits
• Perform any other job duties as requested

Education and Experience:

• Bachelor of Science/Arts Degree in accounting, finance, economics, computer sciences or related field or equivalent work experience is required
• Master of Business Administration (MBA) or other related post-graduate degree is preferred
• Minimum of four (4) years of experience in risk adjustment, decision support, or other analytical role is required
• Strong database (SAS, Access, SQL, etc.) experience is preferred
• Experience in analyzing health data, or other healthcare or Managed Care experience is preferred

Competencies, Knowledge and Skills:

• Advanced proficiency level with Microsoft Excel, advanced proficiency with Microsoft Power Point
• Familiar with a variety of analysis concepts, practices and procedures to effectively report data, analyze facts, and exercise sound business judgment
• Knowledgeable of Medicare/CMS Knowledgeable of ICD-9/ICD-10 and CPT codes
• Wide degree of creativity and latitude (independent judgment) is required
• Ability to work with others and work independently
• Demonstrates analytical/problem solving skills to perform a variety of complicated tasks
• Possesses critical thinking/listening skills
• Ability to communicate with all levels of management
• Detail oriented
• Knowledge of SQL, SAS or other relational database software and/or business intelligence (BI) tools is preferred

Licensure and Certification:

• AAPC or AHIMA coding certification is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to travel  less than 10% of the time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.