Job Summary

Responsible for the development, execution, and management of the risk adjustment data analytics programs for the Medicare Advantage and Medicaid programs. Assists Director in developing a long-term plan for departmental analytics and submissions strategy to support the analytic needs of the organization.

Essential Responsibilities

Technical and Operational Management

• Work with the Director of Risk Adjustment in the execution of Risk Adjustment financial and analytic plans and goals in alignment with organizational vision and goals.
• Develop automated processes to calculate Centers for Medicaid and Medicare Services (CMS) Hierarchical Condition Category (HCC) Risk Adjustment Factor (RAF) models (v24 and v28) and accurately calculate RAF scores for each member.
• Maintain and update RAF calculation processes to account for CMS changes and updates to the model, including evaluation of new proposed RAF models and changes to submission deadlines.
• Oversee monthly Risk Adjustment reporting, including month over month trend analysis.
• Oversee the development of key analytics and data to support Risk Adjustment financial forecasts, analyses and reporting to engage key stakeholders and communicate program results to the organization.
• Analyze RAF build over time and work closely with finance teams to forecast year-end RAF, leveraging historical RAF build, program RAF contribution and demographic changes.
• Establish and maintain technical and procedural infrastructure to support all aspects of Risk Adjustment
• Develop analytics and dashboard tools to track the performance of leading Risk Adjustment and encounter data submissions indicators against targets and effectively communicate performance and insights to internal stakeholders.
• Manage the development of provider-level analytics and reporting that evaluate provider performance and deliver actionable insights for opportunity prioritization. Support operations teams by developing analytics required for operational execution and vendor management (priority lists, chase lists, gap lists, staffing).
• Mentor financial analysts and contribute to analytics training program and project intake.
• Monitor accuracy and timeliness of Electronic Data Processing Systems (EDPS) and Medicaid encounter data submissions to ensure compliance with Centers for Medicaid and Medicare Services (CMS) and Oregon Health Authority (OHA) regulations.
• Attend industry risk adjustment and encounter data training and assimilate learning into processes.
• Perform other duties and projects as assigned.

Relationship Management

• Communicate effectively, encouraging and creating a collaborative culture inside of Strategic Finance and cross-functionally.
• Build and ensure effective relationships across internal teams and external organizations for current or future integration.
• Partner with internal leaders and managers in identifying improvement plans and processes.

Employee Supervision

• Manage team(s) and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
• Train, supervise, motivate, and coach employees; provide support toward employee development.
• Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
• Ensure team adheres to department and organizational standards, policies, and procedures.
• Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
• Perform supervisory tasks in collaboration with Human Resources as needed.

Organizational Responsibilities

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 7 years' experience in the analysis of healthcare data, specifically medical claims and/or encounter data
• Minimum 5 years' experience working with one or a combination of the following: SQL, SAS, Python
• Advanced knowledge of analytics, statistics, and data management

Preferred

• Bachelor's degree in Statistics, Mathematics, Computer Science, or related field
• Master's degree in related field
• Minimum 2 years' experience in a supervisory position or minimum 1 year experience in a supervisory position and completion of CareOregon's Aspiring Leader Program

Knowledge, Skills and Abilities Required

Knowledge

• Understanding of Microsoft SQL Server
• Understanding of statistical software packages, such as SAS
• Understanding of 837 formats and file protocols
• Understanding of risk adjustment theory and CMS model
• Understanding of the CDPS + Rx model
• Understanding of Medicare Advantage and OHP risk adjustment regulations and requirements
• Knowledge of medical claim coding and Medicare Advantage payment methodology

Skills and Abilities

• Proficient with SAS, SQL, and/or Python

• Advanced Excel skills
• Excellent critical thinking and problem-solving skills
• Excellent written and verbal communication skills, including strong presentation skills
• Ability to develop and maintain Tableau dashboards
• Ability to independently gather, compile and analyze data using statistical methods
• Ability to provide leadership and oversight of analytical projects
• Ability to manipulate and analyze statistical data
• Ability to prepare narrative and statistical reports
• Ability to manage the workloads of others and interact effectively and motivate staff to perform at their highest level
• Ability to work with limited supervision
• Ability to manage multiple and competing tasks and priorities

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see for at least 6 hours/day
• Ability to read, hear and speak clearly for at least 3-6 hours/day
• Ability to perform repetitive finger and wrist movement for at least 1-3 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.