the smart solution for Worcester jobs

Risk Adjustment Consultant - Medicare, Risk & Analytics- Fastest Growing Health Insurance.

Company: Fallon Community Health Plan
Location: Worcester
Posted on: January 15, 2019

Job Description:

Job ID: 5166

# Positions: 1

Posted Date: 2018-07-24

Category: Finance

Product Line:


Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


The primary role of the RAC will be to function as the Encounter SME for the Risk Adjustment & Analytics Department. The RAC maintains and operates the Encounter Data vendor software solutions and implements reporting specific to: Edge Server, RAPS, EDPS and Medicaid Encounter data submission analytic reports, as well as analyzes and researches all Encounter data errors and issues, collaborating with internal departments to work toward error resolution.

The Risk Adjustment Consultant will be a SME for the respective risk adjustment model(s) and related Encounter Data submission requirements. The RAC will review and apply all related regulatory requirements to department activities for example: audits, changes in rate models, changes in submissions, audit responses and selection, etc. The RAC will use a combination of SAS, SQL, Risk Adjustment vendor software tools and other commonly used software, such as Excel, to establish an understanding and expertise for the assigned product line(s).

The Risk Adjustment Consultant will be responsible for leading projects and engaging collaborating staff within Finance, IT, Care Services and Operational areas to optimize Risk Adjustment results. The RAC will interface with external and internal customers and vendors to identify and/or analyze business problems and develop solutions, as well as improve workflows and business processes to improve Risk Adjustment outcomes.

The RAC will represent the Senior Director and department in corporate meetings. The RAC will represent the Risk Adjustment team, participating in corporate project workgroups and team initiatives as assigned. The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed.


Analyze & Resolve Claims/ Encounter Data Errors

  • Encounter Data/Claims SME
  • Prioritize error resolution
  • Collaborate with internal departments to work toward error resolution
  • Manage Encounter Data software

    Product Line Support
    • Educate specified product line management on drivers of variances from budget for all revenue streams.
    • Meet regularly with the specified product manager(s) to identify and implement reports to improve revenue optimization efforts.

      Regulatory Compliance
      • Knowledgeable of data submission timelines and lags - RA factor impact
      • SME for regulatory rate release notes and summaries - review and oversee application of risk adjustment changes specific to Annual Rate Notices and interim rate bulletins from state and federal regulatory agencies.

        Corporate Project Support
        • Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as required.


          • BA or BS - Business Administration, Finance, Economics, Healthcare Administration, other
          • Experience working in Medicare, Medicaid and/or Merged Markets support role: Risk Adjustment, Regulatory, Enrollment, Internal Audit, Accounting, Underwriting, Marketing, Claims - other
          • Proficient/Advanced in Excel
          • Ability to create presentations & exhibits in formats that meet various audience levels
          • SQL- Navigator and/or SAS experience
          • -7 years - Managed Care setting
          • -5 years - Excel
          • -3 years - SQL/SAS Experience



            Keywords: Fallon Community Health Plan, Worcester , Risk Adjustment Consultant - Medicare, Risk & Analytics- Fastest Growing Health Insurance., Healthcare , Worcester, Massachusetts

            Click here to apply!

            Didn't find what you're looking for? Search again!

            I'm looking for
            in category

Other Healthcare Jobs

Medical Transcription
Description: positions would be Monday through Friday and would work every 3rd weekend both Saturday and Sunday . When working your weekend in the rotation, you would have Thursday off before working the weekend (more...)
Company: Mommy Jobs Online
Location: Troy
Posted on: 01/18/2019

Physical Therapist (PT) (Full Time)
Description: Full Time Position Genesis Rehab Services is a leading provider of Physical, Occupational, Speech and Respiratory Therapy for older adults in skilled nursing facilities, independent and assisted living (more...)
Company: Genesis Healthcare LLC
Location: Peabody
Posted on: 01/18/2019

Travel Registered Nurse - Med Surg Telemetry RN
Description: Employer is a nationally recognized healthcare staffing provider partnering with a general medical
Company: Supplemental Health Care
Location: Methuen
Posted on: 01/18/2019

Inpatient Primary Care Physician
Description: Family Practice-Without OB opening in Pittsfield, Massachusetts. This and other physician jobs brought to you by DocCafe.com TeamHealth has an excellent opportunity for an experienced physician with an (more...)
Company: TeamHealth
Location: Pittsfield
Posted on: 01/18/2019

Description: LTC Licensed Practical Nurse LPN Do you love fast paced environments in a reputable Long Term Care Facility We have openings in Pittsfield, Massachusetts for Licensed Practical Nurses LPN . Job Details (more...)
Company: General Healthcare Resources, Inc.
Location: Pittsfield
Posted on: 01/18/2019

Registered Nurse / Travel / ER job in Methuen, MA (224668)
Description: Emergency Nurse Massachusetts Currently looking for experienced and energetic ER Registered Nurses for job openings in the Massachusetts area. Interested candidates need to have 2 years
Company: MAS Medical Staffing
Location: Methuen
Posted on: 01/18/2019

RELOCATION OPPORTUNITY: RN - Surgical: Winston-Salem, NC
Description: Overview Novant Health is an integrated system of physician practices, hospitals, outpatient centers, and more - each element committed to delivering a remarkable healthcare experience for patients and (more...)
Company: Novant Health
Location: East Providence
Posted on: 01/18/2019

Med Surg RN - Methuen
Description: Supplemental Health Care is a nationally recognized healthcare staffing provider partnering with a hospital in Methuen, MA to provide a Med Surg RN.Facility Details:The facility is a 385-bed hospital (more...)
Company: Supplemental Health Care
Location: Methuen
Posted on: 01/18/2019

Physician Assistant - General Surgery
Description: Masters degree is required Beth Israel Deaconess Hospital- Plymouth is seeking a Physician Assistant to join our inpatient surgical
Company: Beth Israel Deaconess Hospital
Location: Plymouth
Posted on: 01/18/2019

Healthcare Specialist
Description: Solid 24 year old company is seeking individuals with a desire to help others join our growing team Duties include but not limited to
Company: Shelton Career Center
Location: Troy
Posted on: 01/18/2019

Log In or Create An Account

Get the latest Massachusetts jobs by following @recnetMA on Twitter!

Worcester RSS job feeds