Job Details

Job Details

Job Location
Main Office - Santa Barbara, CA

Remote Type
Fully Remote

Position Type
Full Time

Salary Range
$117904.00 - $176857.00 Salary/year

Job Category
Financial Analytics

Description

Central Coast Salary Range- $117,904 - $176,857

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey, and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

The Sr. Risk Adjustment Analyst will be responsible for supporting the end-to-end risk adjustment program for the CenCal Health Medicare Advantage D-SNP line of business. This position plays a critical role in ensuring that policies and procedures are followed to achieve appropriate risk adjustment revenue from CMS, while ensuring compliance with CMS guidelines, and other regulatory requirements. The analyst will collaborate across Finance, Operations, Compliance, and IT to support revenue accuracy, RADV risk mitigation, and encounter data integrity.

Duties and Responsibilities

• Encounter Data Integrity:
  
  
  • Support business processes for successful submission and reconciliation of encounter submissions to CMS/Medicare.
  • Collaborate with IT, Operations, and vendors to ensure encounter data submissions are timely, accurate, and compliant with CMS requirements.
  • Assist in root-cause analysis of rejected/returned encounters and support corrective action plans.
  • Contribute to preparation for CMS audits and RADV reviews, ensuring complete documentation and compliance.

• Data Analysis & Reporting:
  
  
  • 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.
  • Develop, maintain, and distribute recurring financial and operational risk adjustment reports (MMR, PPR, DTRR, etc.).
  • Monitor revenue trends and risk score impacts, identifying opportunities for improvement.
• Vendor Oversight & Compliance:

• Monitor vendor performance relating to compliance standards and program financial success.
• Coordinate data exchange with vendors and all external stakeholders.
• Support the tracking and reporting for all CMS response files and reports, including MMR, MOR, MAO-002, and MAO-004 reports.
• Support and participate in internal and external audits as needed.

• Cross-Functional Support:
  
  
  • Partner with clinical, compliance, and vendor teams on initiatives that improve documentation and coding accuracy.
  • Provide ad hoc analysis and subject matter expertise to leadership on risk adjustment topics.
  • Support development and implementation of policies, procedures, and training related to risk adjustment data.

• Familiarity with CMS-HCC or HHS-HCC risk adjustment models.
• Experience with analyzing and visualizing large data sets.
• Comprehensive knowledge of Microsoft Office applications, including Word, PowerPoint, Outlook, and Intermediate Excel skills.
• Proficiency in data analysis and reporting, using tools such as SAS, Microsoft SQL Server, Oracle SQL Developer, Toad, Tableau and Power BI.
• Understanding of CMS Medicare Regulatory Requirements.
• Ability to establish and maintain positive professional working relationships, both within and outside CenCal Health.
• Organized, detail oriented, and experienced in maintaining a complex reporting system required.
• Ability to work in a fast-paced, dynamic environment with multiple priorities.
• A proactive approach to identifying opportunities for process improvements and financial efficiencies.
• Strong leadership qualities and the ability to collaborate effectively across departments.
• Must think independently and communicate effectively.

• Bachelor's Degree in Healthcare Administration, Computer Science, Health Information Management, Information Systems, or a closely related field.
• 5+ years of progressive experience in healthcare finance, with a focus on Medicare Advantage. D-SNP program experience a plus.
• 5+ years of experience working with healthcare data, including claims, provider, and enrollment data.
• 3+ years of experience in risk adjustment, either Medicare Advantage, Affordable Care Act, or Medicaid.
• Experience with Cognizant Elements suite of products (EDM, FRM) a plus.