• Risk Adjustment Analyst - Full Time Days - Immanuel Home Office

    Job Locations US-NE-Omaha
    Posted Date 1 week ago(4/17/2018 10:47 AM)
    Job ID
    # of Openings
    PACE Pathways
    The LINK
  • Overview

    Purpose of the Job:  

    The overall purpose of this job is ensuring complete and accurate transmission of and monitoring of Risk Adjustment, Medicare Part D and Encounter Data Processing Systems (EDS) data. The primary responsibilities of this job include monitoring and maintenance of all activities related to Risk Adjustment, including compliance, reporting, analysis and provider education and training. Supports and lives out Immanuel’s Mission and CHRIST Promises.


    Key Areas

    Key Responsibilities and Duties of the Job

    Risk Adjustment Analysis

    • Act as a liaison for the Third Party Administrator (TPA) to maintain risk adjustment and Medicare Part D processes.
      • Monitor True Out of Pocket (TrOOP) out letters
      • Monitor third party coding vendor by reviewing Chart Audit results, query process, Hierarchical Condition Categories (HCC) and zero risk report.  
      • Analyze PACE Data Analysis Center (PDAC) reports to validate risk adjustment scores for reimbursement accuracy.
      • Monitor Prescription Drug Event (PDE) data prior to submission to CMS.
      • Provide admission diagnoses for CMS Quality Utilization reporting.
      • Enter Health Maintenance Codes (diagnosis codes) into the Electronic Health Record (EHR) for all new participants on a monthly basis.
      • Provide assessment details to the third party coding vendor on a monthly basis.
    • Resolve data submission errors from Risk Adjustment Processing Systems (RAPS) and Encounter Data Processing Systems (EDS).
      • Monitor EDS system and lead EDS workgroup.
    • Ensure accuracy and reporting of monthly enrollments and disenrollments to CMS:
      •  Medicare Advantage and Prescription Drug system (MARx) enrollments and disenrollments.
      • Verify Medicare enrollment information in EHR is accurate.
      • Reed & Associates third party retro payments.
      • Monitor Daily transaction reply reports.
      • Review eligibility for Medicare Entitlements.
      • Perform Enrollment Data Validation (EDV) per CMS guidelines.
      • Maintain Participant’s eligibility file.
    • Manage Coordination of Benefits (COB)
      • TrOOP – In letter requests and monitoring.
      • Verify, update and monitor Electronic Correspondence Referral Systems (ESCRS).
      • Monitor COB monthly and annually.
      • Monitor Medicare Secondary Payer (MSP).
      • Monitor Employee Group Union.

    Compliance & Reporting

    • Manage all regulations and deadlines for Risk Adjustment, Medicare Part D and EDS as set forth by CMS.
    • Perform Monthly reconciliation of CMS payment regarding enrollment and disenrollment.
      •  Reconcile and monitor Monthly Membership Report (MMR).
    • Assist with other reporting and analysis as requested.

    Provider Support, Education & Training

    • Assist in the development of provider risk adjustment training materials.
    • Assist with developing risk adjustment departmental policies and procedures.
    • Assist with education and transition of onboarding new providers.


    • Performs other duties as assigned or requested.




    • Bachelor’s degree in a healthcare or business related field required.
    • Equivalent years of experience may substitute for education requirement.



    • Two (2) years of business analytics or related experience is required.
    • Experience with CMS data systems preferred.
    • Equivalent years of education may substitute for experience requirement.


    KSA- Knowledge Skills and Abilities-

    • Knowledge of Medicare payment methodology.
    • Knowledge of CMS reports, specifically MMR, RAPS and EDS submission status reports.
    • Knowledge of Risk Adjustment methodologies, Risk Adjustment Factor Score calculation, governmental programs and HCC coding.
    • Knowledge of data gathering techniques.
    • Skills in working complex program analytics and process improvement activities.
    • Skills in working with multiple PC based software programs including database systems and Microsoft Office.
    • Ability to prepare and analyze reports while making recommendations for improvements.
    • Ability to work with a high degree of autonomy.
    • Ability to exhibit high standard of ethics, accountability and responsibility.
    • Ability to achieve results with little or no supervision and general directions.
    • Ability to professionally and effectively communicate in both verbal and written forms.
    • Ability to communicate complex ideas and strategic recommendations.
    • Ability to anticipate and quickly adapt to meet the needs of audience, clients or projects.
    • Ability to work within tight timeframes and multiple deadlines.


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