Understand managed, at-risk populations, quality program and contractual deliverables
Prepare written analysis and recommendations for future pathway development
Compile, analyze and report on key program data to support clients’ goals, provides guidance in wellness or population health management and helps in program development. Assists with the development of communication with all stakeholders regarding areas of concern on analytical reports, or other functional support areas
Perform analysis of populations and program data to identify key areas of improvement opportunity
Create core reporting dashboards summarizing and trending all aspects of Medicare business, CMS Revenue, Enrollment and Risk Adjustment
Provide and reconcile data and analysis for HCC gaps – health plan and internal data.
Perform data mining of claims, encounters and RAPS/EDS data to identify trends, data issues and members with missing hierarchical condition categories (HCC’s)
Perform audits on submitted claims and encounter data to verify CMS regulatory compliance
Perform cyclical RAPS data submission reconciliation to ensure maximum data throughout
Compare RAPS submission to claims and encounter data, identify claims and encounters that have not been submitted to CMS
Serve as the liaison between departments, markets and data management for all Risk Adjustment reporting needs
Understand the principles of Risk Adjustment based CMS standards.
Identify and propose opportunities for process improvement and prepares written documentation.
Solicit and incorporates input from peers, customers, and management for process improvements. Apply knowledge of new trends in healthcare which may involve data management and analytics.
Qualifications What You Will Need:
Education and Experience Required:
Bachelor’s degree in Actuarial Science, Mathematics, Computer Science, or analytical related field
Minimal 2 years’ experience in a healthcare setting, computer science or operational support/analysis
Technical experience in utilizing software tools and applications
Knowledge and Skills Required:
Excellent knowledge of other aspects of typical health plan operations including network management
Excellent understanding of clinically integrated networks i.e. physician office practice management and inpatient settings
Excellent analytical, problem solving, prioritization and operational skills.
Excellent understanding and use of statistical and graphic displays
Ability to prepare clinical reporting, provide analysis and statistical data the organization can use to make operational changes, target specific goals and refine processes
Ability to prepare clinical reporting, provide analysis and statistical data the organization can use to make operational changes, target specific goals and refine processes
Advanced computer skills, particularly Microsoft Office Outlook, Word, Power Point and Excel
SQL or other programming language.
Job Summary:
The RAF Data Analyst position is part of the PHSO multi-disciplinary team that is responsible for improving both the individual health and wellness of program participants and the overall health status of a client's population. As part of the PHSO Risk Adjustment team the Clinical Data Analyst to identify key areas to drive improvement and to reduce variation in how care is designed and provided role is focused on improving clinical performance across all network regions by analyzing data, by population in order.
The RAF Data Analyst will review, analyze and track clinical, utilization and financial data from multiple sources in order to identify opportunities and determine the activities needed to meet quality targets and employer and payor contractual goals across the continuum. Working collaboratively with the Chief Medical Officer, Finance and Quality leaders, the Analyst will research and produce data related reports to facilitate the identification of best practices and development of protocols, procedures and guidelines to drive performance across populations. The end state, to achieve the goals of the assigned populations served to meet the organizations risk adjustment program and contractual requirements.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
