Welcome to Veradigm, where our Mission is transforming health, insightfully. Join the Veradigm team and help solve many of todays healthcare challenges being addressed by biopharma, health plans, healthcare providers, health technology partners, and the patients they serve. At Veradigm, our primary focus is on harnessing the power of research, analytics, and artificial intelligence (AI) to develop scalable data-driven solutions that bring significant value to all healthcare stakeholders. Together, we can transform healthcare and enable smarter care for millions of people.

Veradigm Payer

Veradigm understands that managed care organizations, pharmacy benefit managers (PBMs), insurance companies, health plans, and other payers need to balance controlling costs with the goal of providing the highest quality of care and optimizing health outcomes for their members.

Solutions from Veradigm Payers:

• Deliver insights to drive quality outcomes cost-effectively
• Improve efficiency for themselves, their providers, and their members through high-speed clinical data exchange
• Impact point-of-care decision making positively by integrating payer guidance and prior authorization management directly in each healthcare providers existing workflow

Job Summary

The Expert Risk Adjustment Analyst will assist our organization as a subject-matter-expert in Medicare Advantage, Affordable Care Act (ACA), Medicaid, and Accountable Care Organization (ACO) Risk Adjustment by developing requirements for new analytics and data products, creating customer financial calculations and projections, and researching customer questions regarding their risk adjustment performance.

Essential Functions

• Develop business cases and requirements for new products and current product enhancements that will benefit our customers risk adjustment goals, working directly with software developers to ensure their coding changes meet business requirements and expected outcomes.
• Lead customer requests for ad hoc reporting or research.
• Own customer financial improvement modeling (examples include: Mid-Year Payment, Final Year Payment, Transfer Payment).
• Lead research initiatives to monitor our internal algorithm performance over time and recommend future enhancements.
• Collaborate with clinicians in outcomes, algorithm performance, and new product development.
• Provide training and guidance to internal and external customers on all facets of the Risk Adjustment process, from initial data capture at point-of-care, through acceptance to CMS, and successfully validated through audit.
• Research and maintain awareness of CMS regulatory guidance and changes, providing expert interpretation for impacts to products and customers.

Job Requirements

• Bachelors degree in Actuarial Science, Math, Statistics, or in a related field of study
• 5 to 7 years of experience analyzing and interpreting Medicare Advantage or Affordable Care Act or Medicaid Risk Adjustment data and models
• Experience supporting the development of scalable analytic and reporting solutions
• Up to 10% travel may be required

Knowledge, Skills and Abilities

• Extensive experience in the healthcare industry, with a focus on Risk Adjustment
• Experience with MA/ACA Risk Scoring methodology, including familiarity with condition categories (HCC, RxHCC, etc.)
• Experience with actuarial or financial modeling concepts
• Experience interacting with large amounts of healthcare data; directly with the following CMS files (MMR, MOR, MAO-004, MAO-002, EDGE RARSD, EDGE RATEE, CCLF)
• Experience working with clinical classification such as diagnoses (ICD), procedures (HCPCS, CPT) and claims processing
• Experience working with data to and from submission systems (RAPS, EDPS, Edge), including background on filtering logic for each system
• Experience with MA mid-year and final year projections and/or ACA transfer payments preferred
• Advance knowledge of SAS, SQL
• Working knowledge of statistics with ability/interest to become proficient
• Proven technical, analytical, detail oriented, and problem solving
• Strong written and verbal communication, with exceptional interpersonal skills to interact with all levels of both external and internal customers
• Ability to work within a team environment
• Experience with Snowflake preferred

Enhancing Lives and Building Careers

Veradigm believes in empowering our associates with the tools and flexibility to bring the best version of themselves to work and to further their professional development. Together, we are In the Network. Interested in learning more?

Take a look at our Culture, Benefits, Early Talent Program, and Additional Openings.

We strongly advocate that our associates receive all CDC recommended vaccinations in prevention of COVID-19.

Visa Sponsorship is not offered for this position.

At Veradigm, our greatest strength comes from bringing together talented people with diverse perspectives to support the needs of healthcare providers, life science companies, health plans, and the patients they serve. The Veradigm Network is a dynamic, open community of solutions, external partners, and cutting-edge artificial intelligence technologies that provide advanced insights, technology, and data-driven solutions. Veradigm offers a comprehensive compensation and benefits package, including holidays, vacation, medical, dental, and vision insurance, company paid life insurance and retirement savings.

Veradigms policy is to provide equal employment opportunity and affirmative action in all of its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity or expression or any other legally protected category. Applicants for North American based positions with Veradigm must be legally authorized to work in the United States or Canada. Verification of employment eligibility will be required as a condition of hire. Veradigm is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse and inclusive workforce.

From a "VEVRAA Federal Contractor" We request Priority Referral of Protected Veterans

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