Lead Risk Adjustment Data Analyst - Hybrid

EmblemHealth; New York (NY); On-site; USD 77,000 - 149,000; Full time

Job summary

EmblemHealth seeks a senior Risk Adjustment Modeling lead to develop and optimize CMS-HCC, HHS-HCC, and RX-HCC models for MA and ACA plans. You will drive analytics to forecast vendor spend, premium revenue, and program efficiency, collaborating with leadership and external partners to align with shared risk initiatives.

You will shepherd complex projects from planning through implementation, ensuring timely delivery and strong stakeholder communication across enterprise risk, finance, product,

Qualifications

• Bachelor’s Degree.
• Master’s Degree in Health or Business Administration (Preferred)
• 5–8+ years of related, professional work experience (Required)
• Experience working with Government Sponsored Health Plans (Required)
• Experience working for a vendor or consultant working with Risk Adjustment Modeling, Bid Submissions (Required)
• Experience in a managed care environment or similar highly regulated industry (Preferred)
• Ability to understand and interpret information and to communicate ideas and information to all audiences (Required)
• Proficiency with Data Programming – SQL, Python, SAS (Required)
• Proficiency with Microsoft Suite - Word, Excel, PowerPoint, Outlook, Teams (Required)
• Detail oriented; ability to think independently and to identify and resolve issues and impediments to project success (Required)
• Excellent communication skills - verbal, written, interpersonal, negotiation; ability to build rapport and relationships (Required)

Responsibilities

• Responsible for building and maintaining internal CMS-HCC, HHS-HCC models, their output and analytics for our MA and ACA plans.
• Partner with leadership on the development of analytics that forecast vendor spend, premium revenue and efficiency of internal Risk Adjustment programs.
• Deliver Risk Adjustment modelling outputs that lead the strategic deployment of our vendors as well as reporting on their efficacy by shared risk/shared savings partners.
• Partner with External Vendors to gain market insights for NYS Medicaid and Essential Plan and develop models to track.
• Partner with the Actuarial Department on model validation and revenue forecasting for all lines of business.
• Track progress and communicate project status on a regular basis to all impacted parties.
• Work with project owners to develop, align, and refine program management oversight to maximize chances for successful delivery of projects.
• Responsible for communicating progress to Enterprise Risk Adjustment leadership and producing status reports presented to the broader Emblem Leadership across Finance, Product, and Provider Network.

Skills

Analytical skills

Stakeholder management

Detail oriented

Education

Bachelor’s Degree

Master’s Degree in Health or Business Administration

Tools

SQL

Python

SAS

Microsoft Office Suite

Job description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

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Lead the development of building a Risk Adjustment Data Modeling and Analytics tool for submissions to CMS-HCC, HHS-HCC, RX-HCC, CRG. Enhance efficiencies within the Risk Adjustment team through data optimization by targeting retrospective and prospective solutions through data modeling. Develop forecasting and efficiency models for contracted Risk Adjustment vendors. Lead the work and deliverables across multiple, complex projects from the planning stage to implementation, that impact multiple processes to optimize functions within the Risk Adjustment department. Align and drive strategic Risk Adjustment cost containment initiatives and goals. Partner with managers, vendors, executive leaders across the enterprise to ensure all workflow processes from Risk Adjustment to their interdependencies are identified and addressed.

Responsibilities

• Responsible for building and maintaining internal CMS-HCC, HHS-HCC models, their output and analytics for our MA and ACA plans.
• Partner with leadership on the development of analytics that forecast vendor spend, premium revenue and efficiency of internal Risk Adjustment programs (collaborations with shared risk\shared savings provider organizations (i.e ACPNY, HCP, and other provider groups) as well as external partners.
• Deliver Risk Adjustment modelling outputs that lead the strategic deployment of our vendors as well as reporting on their efficacy by shared risk\shared savings partners.
• Partner with External Vendors (i.e Solventum) to gain market insights for NYS Medicaid and Essential Plan and develop models to track.
• Partner with the Actuarial Department on model validation and revenue forecasting for all lines of business.
• Track progress and communicate project status on a regular basis to all impacted parties.
• Work with project owners to develop, align, and refine program management oversight to maximize chances for successful delivery of projects.
• Responsible for communicating progress to Enterprise Risk Adjustment leadership and producing status reports presented to the broader Emblem Leadership across Finance, Product, and Provider Network.
• Responsible for capturing follow-ups and takeaways from these meetings.

Qualifications

• Bachelor’s Degree.
• Master’s Degree in Health or Business Administration (Preferred)
• 5 – 8+ years of related, professional work experience (Required)
• Experience working with Government Sponsored Health Plans (Required)
• Experience working for a vendor or consultant working with Risk Adjustment Modeling, Bid Submissions (Required)
• Experience in a managed care environment or similar highly regulated industry (Preferred)
• Ability to understand and interpret information and to communicate ideas and information to all audiences (Required)
• Proficiency with Data Programming – SQL, Python, SAS (Required)
• Proficiency with Microsoft Suite - Word, Excel, PowerPoint, Outlook, Teams (Required)
• Detail oriented; ability to think independently and to identify and resolve issues and impediments to project success (Required)
• Excellent communication skills - verbal, written, interpersonal, negotiation; ability to build rapport and relationships (Required)

Additional Information

• Requisition ID: 1000003353
• Hiring Range: $77,760-$149,040

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.