Job Location

Remote Type

Position Type

Job Summary

The Manager, Risk Adjustment Solutions performs analytic studies. The incumbent will assist our organization as a subject-matter expert in Medicare Advantage and/or Affordable Care Act (ACA) Risk Adjustment by leading business cases for algorithm development and improvement, researching customer queries of analytics performance, and creating requirements for new analytic products.

Position Essential Functions:

• Lead projects to define, create, and implement best-in-class risk adjustment processes, including the facilitation and creation of relevant standard operation procedures (SOPs)
• Develop business cases and requirements for new products and current product enhancements
• Serve as lead for customer requests involving ad hoc reporting or research
• Perform financial improvement modeling and coordinate with internal teams to update models
• Monitor risk score algorithm performance over time and recommend future enhancements
• Collaborate with coders and clinicians in outcomes, algorithm performance, and new product development
• Develop customer presentations and reporting enhancements to streamline operations and support processes.
• Provide training and guidance to clients and other teams on all facets of the Risk Adjustment process, from initial data capture at point-of-care, through acceptance to CMS, and successfully validated through audit.
• Research government regulatory guidance, provide expert interpretation for impacts to PopHealthCare products and customers
• Review and summarize CMS annual payment notice for Medicare Advantage, HHS (ACA), and Medicaid risk adjustment programs
• Ability to work independently as well as contribute to knowledge-sharing within a team environment.

• Minimum Bachelor's degree in Actuarial Science, Math, Statistics, or in a related field of study
• Minimum 4 years of experience analyzing and interpreting MA/ACA Risk Adjustment data
• Experience supporting the development of scalable analytic and reporting solutions
• Extensive experience in the healthcare industry, with a focus on Risk Adjustment
• Experience with MA/ACA Risk Scoring methodology, including familiarity with condition categories (HCC)
• Experience interacting with large amounts of healthcare data
• Experience working with clinical classification such as diagnoses (ICD), procedures (HCPCS, CPT) and claims processing
• End-to-end experience working with risk adjustment submission systems (RAPS, EDPS, EDGE), including background on filtering logic for each system
• Experience with forecasting risk adjustment payments including MA mid-year and final year projections and/or ACA transfer payments
• Advanced knowledge of SAS and experience with SQL.
  

PopHealthCare is an equal opportunity/equal access employer fully committed to achieving a diverse workforce.