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Risk Adjustment Data Analyst III

Company: Blue Cross and Blue Shield Association
Location: Newark
Posted on: November 22, 2022

Job Description:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The Risk Adjustment Data Analyst III is a seasoned analyst responsible for playing an active role in submission, monitoring and contributing to the end to end Risk Adjustment Data Submission and Validation within key regulator guidelines for acceptable data submission.

The analyst will also be responsible for oversight and participation in the timely completion of projects, including timeline development & maintenance as it pertains to encounter and risk adjustment data.

* Collaborate with internal and external stakeholders involved in Risk Adjustment data submission, as well as all other mandatory aspects of Risk Adjustment.
* Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines.
* Research and document encounter errors in established systems and databases with appropriate statistical trend analysis, perform root cause analysis of encounters processing and submission issues and develop recommendations based on data and industry standards.
* Contribute to the creation of technical documents and high level solution designs
* Participate in the development, testing and implementation of system specifications
* Interact with RA leadership to create predictive models using information obtained from data mining or analysis
* Assist in onboarding and coaching of junior analysts. Actively participate in the peer review process by reviewing, providing insight, and verifying work of junior analysts.
* Conduct gap analysis, data collection and validation related to Risk Adjustment activities
* Contribute to program improvement by designing and implementing business process and system changes, collaborate to resolve encounter data and process issues and manage policy and procedure documentation
* Use data from internal and external sources, analyze complex encounter inbound/outbound process issues to provide insight to decision-makers.
* Support and participate in internal and external audits as needed.
* Produce recurring and ad-hoc reports for business stakeholders for risk adjustment optimization.
* Remain informed and updated on industry changes e.g. CMS regulations and changes (EDPS, Risk Adjustment Payment Model Changes).


* Bachelor's degree preferred from an accredited college or university preferably in Computer Science, Data Science or other strong analytical field.
* Master's degree a plus
* Requires a minimum of five (5) years of experience with programming or analytics, preferably in health care, insurance or related field; clinical and medical claims data and disease diagnostic coding practice a plus
* Experience with manipulating large amounts of clinical and medical claims data while working in health care industry, insurance or related field.
* Requires experience using programming and statistical software (e.g., SAS), use of various databases and other data sources, and performing analytics.

Additional Licensing, Certifications, Registrations

* SAS, Oracle, or SQL certification a plus


* Advanced knowledge in Excel (including pivot tables) and Access required
* Advanced knowledge of SAS, Oracle or SQL required
* Knowledge of R and Python is a plus
* Knowledge of risk adjustment programs for Medicare/Medicaid, or risk mitigation programs under ACA, is a plus

Skills and Abilities

* Strong analytical, research and problem-solving skills; experience with relational database and techniques.
* Strong attention to detail
* Written and oral communication skills
* Proficiency in Microsoft software applications
* Ability to perform and interpret a variety of data analyses
* Demonstrated ability to evaluate and interpret complex data
* Demonstrated ability to handle multiple tasks with competing priorities

Horizon 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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Keywords: Blue Cross and Blue Shield Association, Newark , Risk Adjustment Data Analyst III, Professions , Newark, New Jersey

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