Supports initiatives that will impact the Medicare Risk Scores. Collaborates with internal departments and external vendors on risk adjustment projects and to meet business operational needs. Leverages industry resources to increase knowledge and improve return on investment (ROI) of risk adjustment activities. Understands risk adjustment models in emerging business areas, including but not limited to, Medicaid and Medicare products. Becomes a subject matter expert to support business functions, operations and systems. Manages the monthly risk adjustment meetings with key stakeholders to track the effectiveness of the various initiatives critical for risk score accuracy. Works under general supervision.
- Performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies. Must have strong Risk Adjustment experience/knowledge.
- Collaborates regularly with internal departments, including but not limited to, Finance, Medicare Operations, Network Management, Provider Contracting, and Health Economics, and external vendors on risk adjustment projects. Calculates ROI for risk adjustment vendors, initiatives and projects.
- Multitasks and prioritizes various tasks to meet deadlines. Understands various areas of the business and operational processes relevant to the project’s goals.
- Leverages industry resources to increase knowledge and improve ROI of risk adjustment activities. Builds understanding of risk adjustment models in emerging business areas, including Medicaid.
- Maintains current knowledge of CMS’ Hierarchical Condition Categories (HCC) and Prescription Drug Risk Adjustment codes (RxHCCs) including risk adjustment values and formulas.
- Supports response to Risk Adjustment Data Validation (RADV) audits by preparing analytics.
- Assists in performing analyses used in the development of financial plans, re-forecasts, and other financial projections.
- Works with product managers to provide insights into the current state of operations and identify gaps and opportunities for improvement.
- Works on identifying gaps in the claims, encounter reconciliation process, and provides insights to educate providers to improve billing practices.
- Builds reports and dashboards to track risk adjustment related projects and track the effectiveness of the initiatives.
- Tracks compliance requirements and the various business areas using reports and provides evidence of compliance, as needed.
- Interacts with business teams to gather the requirements and translate technical language. Maps documents after the necessary data analysis.
- Participates in special projects and performs related duties as assigned.
Education:Bachelor’s degree in Public Health or related field with equivalent knowledge required. PMP certification preferred.
Experience: Minimum two years of increasingly responsible project management or operations management experience in a healthcare setting required. Knowledge of Medicare Advantage required. Familiarity with medical claims and medical terminology preferred. Proficiency in personal computer programs including MS Excel (including formulas, sorts, filters, pivot tables, IF statements, VLOOKUP, HLOOKUP, etc.), Access (criteria statements, table links, and database and report creation), and Word, required. Experience working with MS project or other project management platform. Effective oral, written and interpersonal communication skills are required.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.