JOB SUMMARY

The Risk Adjustment Analyst Sr (Texas Medicaid Encounter Analyst) is responsible for monitoring and oversight of the end-to-end encounter management workflow. Supports program management activities around risk adjustment data management and submissions to government agencies such as Centers for Medicare and Medicaid Services (CMS) or Health & Human Services (HHS).

SALARY (BASED OFF OF RELEVANT EXPERIENCE)

The pay range for this position is $36.80 (entry-level qualifications) - $57.03 (highly experienced) The specific rate will depend upon the successful candidate's specific qualifications and prior experience.

ESSENTIAL FUNCTIONS OF THE ROLE

• Monitors and oversees the end-to-end claims encounter management workflow.
• Analyzes claims and supplemental data to identify reporting gaps, risk gaps, or sources of incorrect and incomplete diagnostic data.
• Performs 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.
• Using data from internal and external sources, analyzes complex encounter inbound/outbound process issues to provide insight to decision-makers.
• Researches and documents encounter errors in established systems and databases with appropriate statistical trend analysis; performs root cause analysis of encounters processing and submission issues and develops recommendations based on data and industry standards.
• Performs various financial analysis such as revenue forecasting and ROI.
• Contributes to program improvement by designing and implementing business process and system changes, collaborating to resolve encounter data and process issues and managing policy and procedure documentation.
  
  KEY SUCCESS FACTORS
• Advanced knowledge of SQL, MS Excel, MS Access, MS Word, MS Visio and MS PowerPoint.
  • Using SQL, able to design and run intermediate to complex queries and reports from multiple databases.
• Able to independently gather, interpret and analyze data for the purpose of identifying trends, problems and opportunities for improvement.
• Excellent time management and organizational skills with the ability to handle multiple tasks in a timely and accurate manner.
• Able to work under pressure, adhere to deadlines and know when to escalate information and issues.
• Highly motivated and able to work with minimal guidance, independently and as a team participant.
• Outstanding verbal and written communications skills with the ability to communicate clearly to all levels of an organization.
• Ability to work in a high paced environment independently and with cross functional groups.
• Knowledge of ACA, Medicare, Medicaid, MCO, TPA business requirements preferred.
• Experience with healthcare encounters, enrollment and pharmacy data preferred.
  
  BENEFITS
  
  Our competitive benefits package includes the following
  - Immediate eligibility for health and welfare benefits
  - 401(k) savings plan with dollar-for-dollar match up to 5%
  - Tuition Reimbursement
  - PTO accrual beginning Day 1
  Note: Benefits may vary based upon position type and/or level
  
  

QUALIFICATIONS

• EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
• EXPERIENCE - 3 Years of Experience
  • Healthcare billing
  • Texas Medicaid guidelines/billing knowledge
  • Expert in Excel (Pivot tables, importing data, sorting data, etc.)
  • Expert with SQL programming