Risk Adjustment Specialist

MetroPlusHealth; New York (NY); On-site; USD 85,000 - 120,000; Full time

Job summary

MetroPlusHealth in New York City seeks a Risk Adjustment Specialist to drive data capture and accuracy across Medicaid, Medicare and QHP programs. You will monitor vendor submissions, resolve data issues, and coordinate with internal teams and external partners to meet submission deadlines.

You’ll analyze financial impacts, use enterprise data warehouses and dashboards to spot trends, and support end-to-end risk adjustment processes with a detail-oriented approach.

Qualifications

• 3–4 years’ experience in health plan or related finance/PM/actuarial field.
• Bachelor’s degree in Finance, Social Services or Health Care.
• Ability to work independently and resolve problems.

Responsibilities

• Monitor data submitted by vendors to ensure goals are met and data is accurate.
• Identify root causes and remediation plans with internal and external partners.
• Support end-to-end submission processes across Medicaid, Medicare and QHP.
• Perform financial impact analysis of Risk Adjustment activities.
• Analyze data in the enterprise data warehouse to support RA initiatives.
• Use dashboards to identify trends and opportunities in data collection and reporting.

Skills

Independent work

Problem solving

Analytical skills

Stakeholder communication

Education

Bachelor's degree

Tools

SQL

R

SAS

Job description

Position Overview

Risk Adjustment is a growing and critical field within Health Insurance Finance. This is your opportunity

Position Overview

Risk Adjustment is a growing and critical field within Health Insurance Finance. This is your opportunity

to support this function at MetroPlusHealth, New York City’s not-for-profit health insurance company. As a Risk Adjustment Specialist, you will support ongoing processes and lead projects to ensure MetroPlusHealth is fully capturing data about our high-risk populations and submitting accurate information to federal and state agencies. You will work independently to monitor and support internal partners and external vendors in data collection and submission. You’ll apply your problem-solving skills to resolve issues you identify. You will also calculate errors and acceptance rates to track progress over time.

This opportunity is ideal for an individual interested in working at the intersection of Health Insurance Analytics and Operations, who excels at creative problem solving, is detail-oriented, and who is committed to our mission of providing access to health insurance to all New Yorkers.

Scope Of Role And Responsabilities

• Ongoing monitoring of data submitted by vendors to ensure project goals are being met,
• submitted data is complete and accurate, and errors are identified quickly.
• 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.
• Support end-to-end submission processes and encounter data across all lines of business, including Medicaid, Medicare and Affordable Care Act/QHP. This includes monitoring submission timelines, resubmissions, and validating accepted and rejected encounter metrics to ensure data is accurately reflected in downstream reporting.
• Perform financial impact analysis of Risk Adjustment activities, including implications of data errors, missed submissions, and remediation efforts.
• Access and analyze data within the enterprise data warehouse to evaluate member, provider, claims, and enrollment data in support of Risk Adjustment and encounter data initiatives.
• Utilize dashboards to identify trends and potential opportunities in data collection and reportng.

Required Education, Training & Professional Experience

• Bachelor’s degree required, with a demonstrated interest in Finance, Social Services or Health Care.
• Minimum of 3-4 years’ experience required working for a Health Plan, or in a Finance, Project Management or Actuarial capacity in another industry.
• Ability to work independently to investigate, pinpoint, and resolve problems.
• Strong analytical and financial skills. Experience using SQL, R, SAS or another programming language is a plus.
• Proactive communication style and ability to work with a variety of stakeholders to achieve project goals.

Professional Competencies

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

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