Resp & Qualifications
Supports Risk Adjustment & Stars organization to optimize Risk Adjustment revenue and coding accuracy through data-driven approach to closing gaps and risks in coding and care delivery across Medicare & Medicaid populations. Responsible for developing business intelligence and analytics related to Risk Adjustment & Stars programs and processes.
Weight Essential Functions
Develops and works with structured data from multiple sources such as enrollment data, clinical and pharmacy claims data, EMR data, and all risk adjustment related data. Interprets data, analyzes results using statistical techniques, and provides ongoing reports.
Designs, manages, and conducts quality control procedures for data sets using data from multiple systems. Produces regular and adhoc report for business stakeholders to monitor and track Risk Adjustment and Stars performance metrics and enable Risk Adjustment optimization.
Uses business intelligence, statistical, and/or data science techniques to analyze data to guide and evaluate risk adjustment activities (Clinical Programs, Retrospective Programs, RADV Audits and CMS Encounter Submissions.
Collaborates with third party vendors and internal stakeholders including Stars/Quality, Finance and Actuarial areas to optimize Risk Adjustment performance, accurate coding and drive overall quality of care.
Partners with internal and external stakeholders to improve coding accuracy, accurate RAF (Risk Adjustment Factor) and quality through data integration and reporting. Acts as liaison between business partners and technical staff.
Problem Complexity and Problem Solving Timeframes
Provides resolution to an assortment of problems that are typically well defined, but some clarification or judgment is required to determine action, as additional information about the problem / task is discovered. Uses judgment within defined practices / procedures to determine appropriate action. Problem/Task resolution timeframe: Inclusive of shorter timeframes, but the majority of tasks take up to several weeks to resolve.
Level of Supervision Received
Plans and arranges own work, refers only unusual cases to supervisors or others.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor's Degree
Education Details: Data Science, Mathematics, Computer Science, Statistics, Business or related field
Experience: 5 years experience in Risk Adjustment/Quality department with an analytical/quantitative role
4 years of relevant work experience is required in addition to the required work experience.
Knowledge, Skills and Abilities (KSAs) Proficiency
Strong Risk Adjustment knowledge. Proficient
Strong quantitative and qualitative skills. Advanced
Knowledge and understanding of analytical tools such as SAS, Excel, SQL. Proficient
Excellent communication skills both written and verbal Advanced
Ability to learn quickly and take direction. Advanced
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 3/28/2021
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Physical Demands N/A Rarely Occasionally Frequently Constantly Weight
Lifting X 20 lbs
Carrying X 20 lbs
Pushing X 20 lbs
Pulling X 20 lbs
Climbing X 20 lbs
Repetitive Motions X
Eye/Hand/Foot Coordination X
Working Environment N/A Rarely Occasionally Frequently Constantly
Extreme cold X
Extreme heat X
Temperature Change X
Atmospheric Conditions X
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship