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Risk Adjustment Data Validation (RADV) Specialist

Company: Horizon Blue Cross Blue Shield of New Jersey
Location: Newark
Posted on: April 17, 2019

Job Description:

Job Summary:

This position will serve as the primary internal and external contact for all matters related to Affordable Care Act (ACA) and Medicare Advantage (MA) risk adjustment data validation (RADV) audits. Risk adjustment data validation (RADV) process will verify whether diagnosis codes submitted for payment are supported by medical record documentation. This position will aid in ensuring risk adjusted payment integrity and accuracy as the goal of the RADV Audit is to identify any discrepancies by comparing risk adjustment diagnosis data against the data provided to CMS per the RADV audit process. In addition, this position will face off to the entire Enterprise and work with Horizon leadership to ensure all requirements for audits are met in required timeframes.



Responsibilities:

* Is the Lead and primary for internal and external contact for all matters related to Affordable Care Act (ACA) and Medicare Advantage risk adjustment data validation (RADV) audits. Interacts with VPS at Horizon and the main contact at the regulatory agencies.

* Collaborate with Horizon Compliance and other internal departments to obtain data and files needed to satisfy audit requirements. These audits will occur yearly with a sample of the patients served by different segments. The audits are meant to gather information on the health status of the patients; they are not an inquiry into the quality of work of the health care professional.

* Develop, perform, and oversee risk adjustment analytical studies that involve manipulations of large amounts of data. Identify patterns and trends in diagnostic coding practice in conjunction with risk score measurement. Conduct gap analysis and data collection and validation. Analyze enrollment and claims data for patterns and trends to identify opportunity to improve documentation and coding.

* Serve as the point of contact for external auditors and the Center for Medicare/Medicaid Services (CMS), addressing day to day issues and questions, managing weekly and ad-hoc meetings, and transferring data and files to and from auditors and CMS

* Leads and coordinates development of Plan responses to requests for information, data collections, audits, advisory notices, or notices of non-compliance from federal/state legislators and regulators with the Chief Compliance and Risk Officer, Chief Actuary, and other VPs in the organization

* Work with Horizon leadership to ensure all requirements are met in required timeframes. Responsibilities may include, but are not limited to creating project plans, collaborating with leaders across the Enterprise

* Review audit results and develop action plans to improve results in future audits Works closely with business unit leadership to ensure that they and their staffs have the requisite information and knowledge of contractual and regulatory requirements to carry out their responsibilities in a lawful and ethical manner.

* Represents Horizon BCBS in CMS and industry conference calls, webinars, and conferences to obtain all timely and relevant guidance and updates

* Lead cross-functional teams to satisfy audit requirements and achieve desired results, which will include but is not limited to the creation of executive summaries for various leaders across the Enterprise.

Knowledge:

* Knowledge of Affordable Care Act (ACA) and/or Medicare Advantage risk adjustment

* Understanding of healthcare data enrollment, claims, provider data, ICD-10 diagnosis models

* Ability to query and manipulate large data sets

* Ability to work with and manage cross-functional teams

* Intermediate/advanced knowledge of MS Excel, MS Access, SAS, XML

* Knowledge of Hierarchical Condition Category (HCC) models and HCC coding methodologies

Education/Experience:

* Requires a Bachelor s degree, preferably within Mathematics, Statistics, Actuarial Sciences or related field.

* Requires 10 years of experience in the health insurance industry, with a minimum of 2 associated with RADV audits.

* Requires strong organizational, analytical and communication (verbal and written) skills

* Experience managing or responding to CMS audits, preferably Risk Adjustment Data Validation (RADV) audits preferred

* Experience working with external auditors preferred

* This position requires 10% travel



Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Requirements:

Education
Bachelors

Job Level
Individual Contributor

Expertise
Actuarial & Underwriting

Job Type
Full Time

Location
Newark, NJ

Keywords: Horizon Blue Cross Blue Shield of New Jersey, Newark , Risk Adjustment Data Validation (RADV) Specialist, Accounting, Auditing , Newark, New Jersey

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