Health Insurance Revenue Mgmt. Risk Adjustment Analyst III
GENERAL SUMMARY:
To assist the Revenue Management and Risk Adjustment department (RMRA) in ensuring the Financial Reporting and Analysis responsibilities for the oversight of the Revenue Management and/or Risk Adjustment programs for all government funded product lines. Under direction of Department Manager:
PRINCIPLE DUTIES AND RESPONSIBILITIES
• Coordination of monthly and ad hoc data submissions, monitoring data for accurate tracking and reporting of medical, drug claim data and membership data to CMS RAPS, EDPS and DDPS and Edge Server. Produce, distribute, monthly, quarterly, and annual key performance indicators (KPI’s) and error/rejection detail for all report submissions and external vendor support system data correction
• Premium reconciliation reports for monthly financial close; file payment issues with CMS and monitor response; monitor MMR accruals; estimate risk adjustment premium impact for final reconciliation with CMS; allocation of premium to at-risk provider networks
• Maintenance of the following queries and analysis: Reconciliation reports for Risk Adjustment, Reinsurance, Risk Corridors, APTC, Cost Sharing, and Part D program receivables and payables for monthly accounting needs. Monitor accruals for final reconciliation with CMS and cost sharing
• Develop and enhance reporting capabilities for financial and operational performance
• Annual financial reporting activities including CMS bid filings, HCR Premium Development, RFP on financial Risk Adjustment projects, Employer Group Rate Renewals, financial audits, CMS Attestations, premium and member revenue budgets, Medical Loss Ratio reporting
• Produce reports to provide M&B discrepancies in the premium payments from CMS. Team with Membership & Billing staff to identify and resolve enrollment, claims, provider and premium discrepancies. Develop detail to support reporting discrepancies to CMS for discrepancies outside of M&B’s influence
• Monitor CMS material and calls for required compliance and system or process changes. Work with management on design and implementation of the changes
• Development and maintenance of departmental policies and procedures for audit purposes and support department in adhering to HAP Compliance department requirements. Complete routine monitoring of departmental procedures and documentation to demonstrate internal (MAR) and external (CMS) audit readiness
• Coordinate and assigns tasks related to testing IT projects and new system related initiatives and CMS software releases
• Analyze department reports to identify data integrity issues, system and programming problems, and work with management to develop and implement improvement solutions
• Assist department in performing routine assignments, ad-hoc projects and meeting established deadlines. Engage assistance of departmental support analysts in completion of required responsibilities where appropriate
• Perform other related duties as assigned
EDUCATION/EXPERIENCE REQUIRED:
• Bachelor’s degree in Accounting, Finance, Business Administration or a related field (must include financial or accounting related course work) required
• Master’s degree (Finance, Business Administration, etc.) preferred
• Completion of Advanced Access, Excel, GQL, Cognos, or SQL training preferred
• Two (2) years of Accounting/Finance business related experience required
• Two (2) years managing projects and initiatives designed to improve business operations required
• Three to five (3-5) years of experience developing, analyzing, interpreting & trending data preferred
• Experience with Medicare Advantage, Medicare Part D, Medicaid or Qualified Health Plans preferred
• Experience in health care finance preferred
• Affordable Care Act (ACA) experience or knowledge preferred
• Knowledge of HAP’s Core system operations and functionality preferred
• Knowledge of business principles and functions required
• Proficient knowledge of Windows – Excel and/or Access required
• Proficient at using various data sources to develop relevant reporting tools, and to use those tools to enhance processes and procedures required
• Knowledge of accounting and financial reporting principles and business functions required
• Ability to research, analyze, interpret, trend, and implement process improvement initiatives required
• Ability to collect and prepare data for written/oral presentation – report creation and generation required
• The ability to work effectively with all levels within the organization required
• Excellent written and verbal communication skills required
• Well defined problem solving and decision making skills required
• Knowledge of Facets or other Health Insurance Claims/Membership systems preferred
• Knowledge of Medicare and/or Medicare Advantage processes preferred
• Visual Basic preferred
• Experience with Cognos, SQL Developer, GQL reporting tools preferred
To assist the Revenue Management and Risk Adjustment department (RMRA) in ensuring the Financial Reporting and Analysis responsibilities for the oversight of the Revenue Management and/or Risk Adjustment programs for all government funded product lines. Under direction of Department Manager:
PRINCIPLE DUTIES AND RESPONSIBILITIES
• Coordination of monthly and ad hoc data submissions, monitoring data for accurate tracking and reporting of medical, drug claim data and membership data to CMS RAPS, EDPS and DDPS and Edge Server. Produce, distribute, monthly, quarterly, and annual key performance indicators (KPI’s) and error/rejection detail for all report submissions and external vendor support system data correction
• Premium reconciliation reports for monthly financial close; file payment issues with CMS and monitor response; monitor MMR accruals; estimate risk adjustment premium impact for final reconciliation with CMS; allocation of premium to at-risk provider networks
• Maintenance of the following queries and analysis: Reconciliation reports for Risk Adjustment, Reinsurance, Risk Corridors, APTC, Cost Sharing, and Part D program receivables and payables for monthly accounting needs. Monitor accruals for final reconciliation with CMS and cost sharing
• Develop and enhance reporting capabilities for financial and operational performance
• Annual financial reporting activities including CMS bid filings, HCR Premium Development, RFP on financial Risk Adjustment projects, Employer Group Rate Renewals, financial audits, CMS Attestations, premium and member revenue budgets, Medical Loss Ratio reporting
• Produce reports to provide M&B discrepancies in the premium payments from CMS. Team with Membership & Billing staff to identify and resolve enrollment, claims, provider and premium discrepancies. Develop detail to support reporting discrepancies to CMS for discrepancies outside of M&B’s influence
• Monitor CMS material and calls for required compliance and system or process changes. Work with management on design and implementation of the changes
• Development and maintenance of departmental policies and procedures for audit purposes and support department in adhering to HAP Compliance department requirements. Complete routine monitoring of departmental procedures and documentation to demonstrate internal (MAR) and external (CMS) audit readiness
• Coordinate and assigns tasks related to testing IT projects and new system related initiatives and CMS software releases
• Analyze department reports to identify data integrity issues, system and programming problems, and work with management to develop and implement improvement solutions
• Assist department in performing routine assignments, ad-hoc projects and meeting established deadlines. Engage assistance of departmental support analysts in completion of required responsibilities where appropriate
• Perform other related duties as assigned
EDUCATION/EXPERIENCE REQUIRED:
• Bachelor’s degree in Accounting, Finance, Business Administration or a related field (must include financial or accounting related course work) required
• Master’s degree (Finance, Business Administration, etc.) preferred
• Completion of Advanced Access, Excel, GQL, Cognos, or SQL training preferred
• Two (2) years of Accounting/Finance business related experience required
• Two (2) years managing projects and initiatives designed to improve business operations required
• Three to five (3-5) years of experience developing, analyzing, interpreting & trending data preferred
• Experience with Medicare Advantage, Medicare Part D, Medicaid or Qualified Health Plans preferred
• Experience in health care finance preferred
• Affordable Care Act (ACA) experience or knowledge preferred
• Knowledge of HAP’s Core system operations and functionality preferred
• Knowledge of business principles and functions required
• Proficient knowledge of Windows – Excel and/or Access required
• Proficient at using various data sources to develop relevant reporting tools, and to use those tools to enhance processes and procedures required
• Knowledge of accounting and financial reporting principles and business functions required
• Ability to research, analyze, interpret, trend, and implement process improvement initiatives required
• Ability to collect and prepare data for written/oral presentation – report creation and generation required
• The ability to work effectively with all levels within the organization required
• Excellent written and verbal communication skills required
• Well defined problem solving and decision making skills required
• Knowledge of Facets or other Health Insurance Claims/Membership systems preferred
• Knowledge of Medicare and/or Medicare Advantage processes preferred
• Visual Basic preferred
• Experience with Cognos, SQL Developer, GQL reporting tools preferred