Risk Adjustment Data Analyst III

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

The Risk Adjustment Data Analyst III is a seasoned analyst responsible for playing an active role in submission, monitoring and contributing to the end to end Risk Adjustment Data Submission and Validation within key regulator guidelines for acceptable data submission.

The analyst will also be responsible for oversight and participation in the timely completion of projects, including timeline development & maintenance as it pertains to encounter and risk adjustment data.

What You'll Do

-Collaborate with internal and external stakeholders involved in Risk Adjustment data submission, as well as all other mandatory aspects of Risk Adjustment.

-Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines.

-Research and document encounter errors in established systems and databases with appropriate statistical trend analysis, perform root cause analysis of encounters processing and submission issues and develop recommendations based on data and industry standards.

-Contribute to the creation of technical documents and high level solution designs

-Participate in the development, testing and implementation of system specifications

-Interact with RA leadership to create predictive models using information obtained from data mining or analysis

-Assist in onboarding and coaching of junior analysts. Actively participate in the peer review process by reviewing, providing insight, and verifying work of junior analysts.

-Conduct gap analysis, data collection and validation related to Risk Adjustment activities

-Contribute to program improvement by designing and implementing business process and system changes, collaborate to resolve encounter data and process issues and manage policy and procedure documentation

-Use data from internal and external sources, analyze complex encounter inbound/outbound process issues to provide insight to decision-makers.

-Support and participate in internal and external audits as needed.

-Produce recurring and ad-hoc reports for business stakeholders for risk adjustment optimization.

-Remain informed and updated on industry changes e.g. CMS regulations and changes (EDPS, Risk Adjustment Payment Model Changes).

What You Bring

Education/Experience

• Bachelor’s degree preferred from an accredited college or university preferably in Computer Science, Data Science or other strong analytical field.
• Master’s degree a plus
• Requires a minimum of five (5) years of experience with programming or analytics, preferably in health care, insurance or related field; clinical and medical claims data and disease diagnostic coding practice a plus
• Experience with manipulating large amounts of clinical and medical claims data while working in health care industry, insurance or related field.
• Requires experience using programming and statistical software (e.g., SAS), use of various databases and other data sources, and performing analytics.

Additional Licensing, Certifications, Registrations

• SAS, Oracle, or SQL certification a plus

Knowledge

• Advanced knowledge in Excel (including pivot tables) and Access required
• Advanced knowledge of SAS, Oracle or SQL required
• Knowledge of R and Python is a plus
• Knowledge of risk adjustment programs for Medicare/Medicaid, or risk mitigation programs under ACA, is a plus

Skills and Abilities

• Strong analytical, research and problem-solving skills; experience with relational database and techniques.
• Strong attention to detail
• Written and oral communication skills
• Proficiency in Microsoft software applications
• Ability to perform and interpret a variety of data analyses
• Demonstrated ability to evaluate and interpret complex data
• Demonstrated ability to handle multiple tasks with competing priorities

Travel (If Applicable)

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$87,300 - $119,070

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.