Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Manager of Risk Adjustment Analytics is responsible for the deployment of comprehensive, compliant risk adjustment analytics. This role develops strategies to ensure risk adjustment data accuracy, coordinate the work of clinical and operations partners, and respond to new requirements from CMS or company leadership. Prepare performance reporting and analyze the success of various risk adjustment strategies. Your scope of work will include Medicare and ACA populations.

• Oversee the development and on-going support of key analytics including leading indicators and KPI’s that support management of Capital’s Risk Adjustment programs.
• Using both internally supported analytics as well as vendor reporting to identify and continually monitor member- and provider-facing activities to inform member targeting strategies
• Support prospective efforts by developing and maintaining operational reports to assist physicians in understanding their opportunities to improve documentation and provider level analytics that evaluate provider performance and deliver actionable insights for opportunity prioritization.
• Assess our Risk Adjustment programs and vendors by performing analytics such as campaign and targeting level valuation, tracking and comparison of year over year operational metrics and initiative level ROI to provide input for program and vendor strategy refinement.
• Support operations team by collaborating to develop analytics required for operational execution and vendor management (chase lists, priority lists, gap lists, etc)
• Work closely with Actuary and other stakeholders to supply RAF analytics outputs for broader integration and ensure RAF data is correctly utilized
• Conduct in-depth analysis of critical issues, including claims, enrollment and provider coding trends to support collaborative resolution to issues that impact risk adjustment
• Create and maintain dashboards for internal and external reporting that are accurate, up-to-date, and clearly convey insights
• Serve as Subject Matter Expert for all things data analytics & reporting related to Risk Adjustment at Capital

Skills:

• Advanced analytical skills, including using SQL or other programming language to query large relational databases
• Experience in building and maintaining reports (Power BI or other reporting tool)
• Proactive communication style and ability to work with a variety of stakeholders to achieve project goals

Knowledge:

• Expert level understanding of MA and ACA data sets including claims, eligibility, provider and CMS/HHS data files
• Deep understanding of compliance within risk adjustment and how it supports the organization’s viability.
• Moderate level knowledge of CMS and HHS Risk Adjustment models

Experience:

• 5 years of experience in risk adjustment in a Medicare Advantage or ACA environment.
• 3 years experience with healthcare data specifically medical claims and/or encounter data.
• 3 years experience with SQL, Python or other programming language.
• 1 year staff, team lead or project lead experience

Education and Certifications:

• Bachelor’s degree or 9 years experience in healthcare data & reporting in lieu of degree.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.