Manager Risk Adjustment Data Analytics

The Manager, Risk Adjustment Data Analytics is responsible for leading Data Analytics staff in designing and reporting accurate analytics for the Affordable Care Act (ACA) and Medicare Advantage (MA) Risk Adjustment Data to the Centers for Medicare & Medicaid Services (CMS), developing and executing Risk Adjustment improvement initiatives in coordination with multiple corporate divisions and vendors, and overseeing the estimation of Risk Adjustment payments. Position works jointly with Underwriting, Actuarial Research, Accounting, Provider Relations, Medical Affairs, Compliance, CMS Programs, and Information Technology & Services to generate meaningful reports, produce financial estimates, and identify and act on Risk Adjustment opportunities. Position manages multiple vendor relationships and processes to ensure data integrity.
This position is eligible to work hybrid. remote or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

• Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
• Lead and Inspire: Guide and mentor your team to achieve their full potential and success.
• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
• Trust: Work for one of the most trusted companies in Kansas
• Flexibility: options to work onsite, hybrid or remote available
• Balance: paid vacation and sick leave with paid maternity and paternity available immediately upon hire
• Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.

• Ensure the timely reporting of federal Risk Adjustment Data to CMS via the EDGE Server (ACA) and RAPS and EDPS (MA). Manage multiple vendor relationships and processes to ensure receipt and/or protection of significant ACA funds and MA revenue.
• Review and update the policies, procedures, and programming specifications for creating and editing EDGE Server data files for EDGE Server processing, either internally or through a TPA vendor, as required to meet CMS guidelines and internal decisions.
• Communicate and coordinate EDGE Server file processing and output review with IT&S and/or TPA vendor and manage the editing of data for resubmission. Communicate issues or concerns with IT&S and/or TPA vendor and resolve problems as they arise, recognizing any contractual agreement(s) and established business relationship(s).
• Oversee Discrepancy Reporting and the review of Data Quality Analysis Reports, comparing CMS reports and EDGE Server output to the input data for reasonability. Report any issues or concerns to CMS within specified timelines.
• Monitor MA Risk Adjustment reporting and review data quality reports prior to approval and submission to CMS.
• Oversee development of predictive analytics program and outputs to Retrospective and Prospective Programs.
• Lead development of dashboards to capture provider KPIs.
• Develop and implement standard set of reports for Risk Adjustment Analytics Program.
• Oversee the calculation and estimation of Risk Adjustment payments and MA Stars scores, for use in actuarial models and accounting entries. Review and approve Risk Adjustment estimates and handle communications with consulting vendor.

• Bachelor’s degree in Statistics, Mathematics, Finance, Health Care or Business Administration, Management, or related field.
• Proven experience with advanced Data Analytics, predictive analytics, or Risk Adjustment.
• Strong leadership skills to include knowledge of team concepts while promoting employee engagement.
• Proficient at managing multiple projects simultaneously with experience in prioritizing activities based on immediate business needs.
• Ability to accurately interpret CMS guidelines in providing direction to Risk Adjustment and supporting staff for the purpose of developing, refining, and implementing procedures and operations that maintain high standards for the timely and accurate reporting of actionable information to relevant stakeholders.
• Effective use of interpersonal, negotiation and communications skills including tact and diplomacy. This position maintains interaction with members of CMS staff, vendors for Risk Adjustment, MA Stars, and MA operations, and senior leadership.
• Must have the ability to communicate, influence, and drive outside stakeholders toward high expectations of plan performance necessary for optimal Risk Adjustment analytics.
• Must have excellent written and oral communication skills as the primary point of contact in relation to Risk Adjustment analytics.
• Maintain current knowledge, skill and abilities in Risk Adjustment and MA Stars theories, practices, and technologies.
• Ability to make decisions using independent judgment and creativity to resolve Risk adjustment issues.

• Master’s degree or relevant leadership
• Experience and knowledge in the healthcare delivery system, insurance finance, and the health insurance industry. Knowledge of compliance, information systems, and other health insurance administration concepts and principles.
• Experience with and an understanding of data warehouse, data extraction tools, and analytics software and methods.
• Experience with and an understanding of industry best practices for commercial and MA Risk Adjustment.
• Understanding of CMS EDGE Server, RAPS, EDPS, and MA Stars reporting requirements and the Risk Adjustment and MA Stars models and factors.

March 19, 2024 Salary