Your Role

The Risk Adjustment Provider Partnership team provides essential support to all functions within the risk adjustment program, which includes interaction with various cross-functional teams within Blue Shield and Provider Groups. The Risk Adjustment Consultant, Senior will report to the Manager, Risk Adjustment Provider Partnership. In this role, you will interface with Provider Group operational and clinical leadership to assist in identifying operational and clinical practices in maximizing recapture rates, understanding clinical suspects, and monitoring appropriate clinical documentation and accurate coding. The Risk Adjustment Consultant, Senior will also coordinate the implementation of Blue Shield Programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines and manage administrative projects within the Risk Adjustment Provider Partnership team. The ideal candidate possesses excellent customer service skills, project management skills, organizational skills, analytic skill, self-starter, and high attention to detail.

Your Work

In this role, you will:

• Analyze information for core principles and functionality of decision, descriptive and predictive analytic methods including forecasting, statistical and machine learning techniques
• Train lower-level analysts on how to update and apply these advanced analytic techniques
• Contribute to successful programs for the team, engaged multiple areas related to vendor oversight, internal cross-functional partnerships, tracking performance and measuring results
• Lead data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
• Manage the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs and/or products
• Consult with Provider Groups to drive improvements in support of their risk adjustment processes through developing comprehensive, provider specific plans to increase their RAF performance and improved their coding specificity
• Assisting Provider Groups in understanding the CMS-HCC Risk Adjustment as it relates to payment methodology through their claims/encounter submissions and the importance of proper chart documentation of procedures and diagnoses coding
• Works with Provider Engagement Director and Manager to develop and drive overall risk adjustment strategies
• Utilize analytics and identifies targeted providers for Risk Adjustment training and programs through routinely consulting with Providers to clarify missing or inadequate information to determine appropriate diagnostic and procedure codes
• Work closely with Analytics team and internal departments to gather monthly reporting and ensure correct reports are sent to Provider Groups
• Manage internal administrative projects and monitor department inbox with requests from Provider Groups and key internal departments

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires at least 3 years of professional experience
• Candidate has knowledge of ICD-10, Risk Adjustment, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management and/or provider network management areas of a healthcare-related company
• Candidate has had 2 years' experience facilitating meetings and presenting program education, metrics and results to external parties or internal leadership
• Requires an understanding of clinical metrics, claims/encounters and analytics
• Proficient in Excel, Word, PowerPoint, and Outlook

Pay Range:

The pay range for this role is: $ 96800.00 to $ 145200.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.