Senior Risk Adjustment Specialist

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Senior Risk Adjustment Specialist is a critical team member in the execution of the MetroPlusHealth Risk Adjustment strategy. Your responsibilities will include management of vendors and reporting on their performance, including identifying and resolving issues. You will collaborate with internal and external partners to identify new opportunities and resolve issues as they arise. You will also use SQL and database skills to prepare reports, monitor progress, and provide ongoing and ad-hoc reports to critical partners. In addition, you will assist the Coding Quality team where needed on internal or external diagnosis coding audits. The ideal candidate will have a background in Healthcare Analytics, Health Plan Financial Reporting and/or Risk Adjustment.

• Use SQL or another programming language to query our Enterprise Data Warehouse to prepare reports and create Key Performance Indicators (KPIs).
• Use data to measure performance of external stakeholders, communicate results and create plans to improve outcomes.
• Proactively work with external and internal partners to resolve issues - this includes identifying the root cause, devising plans to remediate, and ensuring on-time completion from all stakeholders.
• Independently manage various projects related to risk score accuracy, including supplemental chart reviews, provider outreach and member engagement.
• Work with Coding Quality team to ensure diagnosis code capture is accurate and that audits are responded to in a timely manner.
• Apply your understanding of Risk Adjustment Models and State and Federal regulatory guidelines to ensure all projects are conducted in a compliant manner.

• Bachelor of Arts degree. Master's degree preferred.
• 5+ years' experience in health care, including at least two years at a health plan in the Finance, Analytics or Product departments.
• At least two years' experience demonstrating results on multiple Risk Adjustment projects, including at least two of the following Risk Adjustment models: HHS-HCC, CMS-HCC and/or 3M CRG.
• Must be able to work independently to manage multiple concurrent coding initiatives and projects.
• Experience working collaboratively with Risk Adjustment vendors and provider partners to achieve results.
• Understanding of federal and encounter submission and diagnosis coding regulatory policies
• Experience using SQL, R, SAS or another programming language.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

#LI-Hybrid

#MPH50