The Capital BlueCross Risk Adjustment, ACA Analyst works with the Director, Risk Assessment and Management in support of internal and external risk revenue management interactions and programs for government commercial ACA programs. This position supports the development and implementation of strategic direction for the risk assessment, submission, and program management processes with the focus of accurate and timely submissions of all applicable risk information, assessment and management of program costs and resources, and improves the quality of care for members. The position supports the coordination of program activities with multiple stakeholders to implement and execute on the strategic direction, optimize revenue management activities and capabilities, build strong analytical functions in order to efficiently and effectively utilize resources, and most importantly ensures that all risk assessment and management activities are conducted in a highly ethical and compliant manner. The position supports the development and implementation of “Risk-related” policies and procedures. In addition, the position supports the development of Risk Assessment and Management Program governance strategies for the Enterprise to appropriately manage CMS audit risk.
Development and Management:
Support the development of and oversee programs to ensure comprehensive and accurate diagnosis coding for risk adjusted government commercial ACA programs. Also, work with Care Management to ensure that this information is used to improve the management of a member’s care.
Collaborate with key internal stakeholders (Clinical Services, Network Contracting, Actuarial, and Compliance) to support the development, implementation, and continual refinement of prospective and retrospective diagnosis coding programs and provider support.
Support the execution of all coding programs and processes, both vendor supplied and internal.
Support the monitoring and analysis of the effectiveness of programs, processes, infrastructure, and reporting, and make changes to improve results and effectiveness.
Identify, evaluate and implement new programs or modifications to existing coding programs and develop strategies to implement.
Develop, oversee and adapt infrastructure (processes, systems, talent) to support an effective risk adjustment program as CMS/HHS evolves the models and guidance.
Accountable for monitoring budget targets related to risk adjustment activities and escalating identified issues or concerns.
Complying with all government and commercial regulations.
Quality Assurance/ Compliance
Monitor and identify process improvements for the governance structure that provides oversight of the governmental audit and compliance risks.
Support the evaluation of and education to senior management of the risk and rewards involved in risk assessment and management programs and strategies.
Support the Risk Assessment and Management Director in collaboration with the Government Program Compliance Officer in the ongoing development, execution and refinement of the quality assurance program to monitor, audit and improve the CBC Risk Assessment and Management Program.
Support the development and implementation of remediation strategies as needed with individual providers, provider groups and the network.
Analytics
Utilize analytics to identify trends and opportunities for improvement, new strategies and further program development.
Collaborate with Actuarial to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals.
Develop capabilities to identify both opportunities and weaknesses in the government’s actuarial risk score models to inform better business decisions.
Operations and Data Submission
Monitor and escalate issues and concerns around the submission of accurate and comprehensive data to the government.
Monitor and escalate issues and concerns around the Edge Server submissions for the ACA products.
Support the development, implementation and control monitoring and reporting to ensure effective processes are in place throughout the organization.
Monitor and escalate issues and concerns around the timely correction and resubmission of data errors from CMS.
Vendor Management
Support the management of vendor relationships, Scopes of Work, and budgetary requirements for the CBC Risk Assessment and Management Program.
Support collaboration with Procurement and Vendor Management to execute Risk Assessment and Management vendor contracts with strong compliance and financial protections.
This position requires the same support and services to Vibra Health Plan and CBC.
Perform other duties as assigned.
Leadership:
Able to support the direction of numerous Departments and Divisions via a matrix-accountability
Relationship management experience that demonstrates the ability to set priorities and meet objectives for complex projects involving multiple stakeholders, and execute according to plans.
Knowledge:
Comprehensive knowledge of ACA programs.
Detailed knowledge of the ACA Risk Revenue programs.
Extensive analytical and financial knowledge.
In-depth understanding of key applicable federal, state, local and international legislation, ability to develop and/or interpret complex regulatory or legal documents and ability to communicate technical and complex concepts.
Skills:
Significant analytic and program management skills.
Excellent communication and interpersonal and relationship management skills to develop and maintain reciprocal, collaborative relationships.
Experience:
Minimum 7 years of experience in compliance and/or enterprise risk management.
Prefer minimum of three years’ demonstrated leadership experience in financial, legal, compliance, enterprise risk management and/or audit profession(s).
ACA Risk Revenue program experience.
Project management experience.
Financial and analytic experience.
Education, Certification, and Licenses:
Bachelor’s Degree and/or Master’s Degree. Focus in Data Analytics, Finance or Actuarial Science, Mathematics or Statistics, Public Health or Health-related Sciences, or Health Administration preferred.
Physical Demands:
While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.
Number of direct and indirect reports:
Due to the corporate-wide, cross-functionality of the Risk Revenue Programs and metrics, far too many “indirect reports” to quantify.
Budget Responsibilities:
Support the management of internal budgets of more than $4 Million.
Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.
