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Senior Risk Adjustment Data Engineer
  • SQL
  • SAS
  • Data Analysis
  • Excel
  • Database
  • Modeling
Neighborhood Health Plan of RI
Smithfield, RI 02917
171 days ago
Overview:The Senior Risk Adjustment Data Engineer position supports, compiles and reports key information created, enhances and maintains for regulatory submissions, reporting, budget or financial models, or benchmarks for an Affordable Care Act or Medicare Risk Adjustment as prescribed by Center for Medicare and Medicaid Services, Department of Health, Health and Human Services or other State and Federal Regulatory Agencies. This position will function in conducting and manage outcome of various data points that may include, analyzing, reviewing, forecasting, and trending of data to support health plan Risk Adjustment Financial Strategy. The position will contribute to the development of business requirements, functional requirements, solution design, process flow and other related documentation for supporting the Regulatory Submissions. The position will take ownership of business processes and develop procedures to mitigate audit risks. The Senior Risk Adjustment Data Engineer position will ensure that the appropriate development standards are met.Responsibilities:
  • Enable Risk Adjustment Program Analytics by developing a data reconciliation model that compares submitted claims and return files to drive RAF improvement.
  • Correlate the differences in Risk Scores to Claims Acceptance Rate and empower the Encounter Data Submissions team to drive towards the desired outcomes.
  • Enable the Operational processes to address and resolve the rejected claims in a timely manner.
  • Develop Analytical Modeling to value the claims accepted versus claims rejected / outstanding.
  • Develop discipline around data management and data integrity to mitigate data (member diagnosis) leakage.
  • Develop processes to ingest the return files from the regulatory agencies for different lines of business.
  • Contribute to the development of business requirements, functional requirements, solution design, process flow and other related documentation for supporting the Regulatory Submissions.
  • Develop the Financial Accrual Model and Risk Transfer Model to correlate Member Comorbidity with Premium.
  • Support strategies for effective monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.
  • Assume ownership of business processes and develop procedures to mitigate audit risks.
  • Develop and implement programs that will enhance provider training and education of the HCC Risk Adjustment Process, Proper Medical Record Documentation and Diagnosis Accuracy.
  • Drive towards the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.
  • Provides guidance to junior-level analysts on data management, data analysis techniques, communication with non-technical stakeholders, project management, and healthcare industry knowledge.
  • Other duties as assigned
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
  • Bachelor Degree in Information Technology, Computer Science, Mathematics, Statistics, Business or Finance
  • 5 years of progressive industry experience in data analysis and tools.
  • 2-3 years’ experience in Health Plan Operations to include Risk Adjustment Activities
  • Experience and strong participation within a Risk Adjustment Team as the primary point of contact for Encounter Data Submissions Team.
  • Experience translating business and design requirements into technical requirements for Risk Adjustment as outlined by CMS or other State Regulatory Requirements.
  • Previous experience in risk adjustment activities in a Medicare, Affordable Care Act or provider organization to including submission of RAPs, and EDPS, EDGE Server files submission, responses and reconciliation per CMS and other State and Federal Guidelines.
  • Experience with business and technical requirements of all inbound and outbound data associated with a strong Risk Adjustment Business Unit.
  • Experience in critical analysis on information from multiple sources, identify issues and break down high-level information into detailed workable plan.
  • Serve as a resource between Risk Adjustment Team and all Operational Business Units to include Encounter Data Submissions, Finance and other departments that may need understanding of the overall Technical aspect of the Risk Adjustment submission and reporting process.
  • Knowledge of claims coding and payment methodology, associated with a Health Plan domain.
  • Advanced analytical problem solving skills.
  • Advanced skills with Microsoft Office (Project, Word, Excel, PowerPoint, Outlook)
  • Demonstrated experience in Data Analysis using various analysis tools (SQL, SAS, etc.) and a strong understanding of database concepts.
  • Demonstrated experience in collaboration, teamwork, and cross-functional communication.
  • High level organizational and project management skills in order to effectively handle concurrent assignments.
  • Advanced Degree or Certifications in related field
  • Strong knowledge base of data points associated with the end to end process of plan payment.
  • Strong background in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) Methodologies.
Core Company-Wide Competencies:
  • Communicate Effectively
  • Respect Others & Value Diversity
  • Analyze Issues & Solve Problems
  • Drive for Customer Success
  • Manage Performance, Productivity & Results
  • Develop Flexibility & Achieve Change
Job Specific Competencies:
  • Collaborate & Foster Teamwork
  • Create & Innovate
  • Exercise Sound Judgement & Decision Making
  • Achieve Professional Growth
FDR Oversight: N/A
Flexible Work Arrangement:
  • Yes
Telecommuting Arrangement:
  • Yes, 2 days a week
Travel Expectations:
  • Some travel locally between locations is required
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at

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