Job Description

Job Summary

Under the supervision of the Director of Data and Reporting, this individual will be responsible for supporting critical data submission functions for the Risk Adjustment Department (RAD), including submissions to CMS and state agencies. The individual will handle internal data reconciliations and data transfers between Point32Health and external stakeholders such as vendors and provider organizations.

This role requires strong analytical skills and the ability to synthesize large data sets and complex information into key insights. The individual will work effectively across business areas and often lead collaborative projects. They will need to follow complex business processes, consider options when problems arise, and identify and escalate issues appropriately.

Key Responsibilities/Duties – what you will be doing

Data Submission Integrity

• Support the director across a range of activities, including monthly encounter data submission to the Executive Offices of Health and Human Services (RI and MA), CMS and APCD (All-Payer Claims Database) submissions to state agencies.
• Monitor ongoing encounter data/APCDs response files to identify and address discrepancies in a timely manner.
• Review monthly error reports, perform trend analysis, investigate critical errors, and work with the appropriate business area on resolution.
• Enhance and automate existing reconciliation and reporting code using advanced SAS and/or SQL skills.
• Interface with IT for the implementation of enhancements and timely resolution of production issues pertaining to state government and risk adjustment data submissions, including issue investigation, business requirements, user acceptance testing, and post-implementation monitoring.

Reporting and Data Management

• Use Tableau, Cognos, and Excel to create monthly submission dashboards and run submission reconciliations to effectively track acceptance rates and submission trends.
• Create various reconciliations and ad hoc reports.
• Use SAS to extract and transform data to create reports from multiple sources.
• Assist Strategy and Operations team with the implementation of new program vendors, including data file transfers and reviews of internally received files for completeness, reasonableness, and accuracy.
• Establish and manage data transfer methods with vendors, including working with IT to set up and manage secure file transfer sites for vendors that support our risk adjustment programs.

Collaboration with Internal/External Stakeholders

• Collaborate effectively within risk adjustment department and other internal stakeholders, including Claims, Member Operations, Information Technology, and Provider Information, to ensure that process enhancements and submission mechanisms are maintained and monitored.
• Collaborate with federal agencies, vendor data management staff, and industry trade associations to stay up to date with changes and updates from EOHHS and other state agencies.
• Effectively communicate regulatory updates to the team and department leadership and escalate risks appropriately.

Data Analysis

• Conduct ad hoc analyses specific to risk score trends, truncation report, data/claims submissions and program performance to support risk adjustment analytics; deliver timely and accurate information to contracted provider groups.
• Create, compile, and format presentations for a variety of audiences, including supporting worksheets, graphics, and supplemental documents.

Administration

• Attend meetings, document key decisions, manage follow up actions as necessary.
• Serve as department point of contact for various internal and external initiatives, including interdepartmental projects across Point32Health business lines.
• Create and manage business policies and procedures and knowledge repositories for the department as needed.

QUALIFICATIONS – what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE:

• Bachelor's degree required, preferably in related field such as health informatics, business analysis, IT, finance, decision modeling.

  EXPERIENCE (minimum years required) :

• Three to five years of experience in analytical roles in the health care or health insurance sector either for a health plan, provider group, healthcare IT / management consultancy or auditing firm.
• Understanding of claims systems, provider information, Medicaid/Medicare, and/or experience working with large data sets preferred.

• Engaged, critical thinker, organized, detail-oriented, resourceful, and self-motivated.
• Comfortable working with large data sets from disparate sources, and able to identify relevant patterns and trends.
• Expertise in SAS Enterprise Guide/ SAS Base and SQL/ProcSQL (SAS certification preferred).
• Experience with database software and reporting tools such as SQL Server, Oracle, and Cognos.
• Experience with Alteryx, Cloudera and Tableau is a plus.
• Proficient in Microsoft Excel, PowerPoint, and Word.
• Strong interpersonal and communication skills.
• Ability to work collaboratively with both internal and external resources.
• Ability to take responsibility, prioritize tasks and follow through to completion.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel) :

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Scam alert : Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8273

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