Risk Adjustment Program Lead

Job not on LinkedIn

🔥 2 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $75.4k - $140k / year

⏰ Full Time

🟠 Senior

🎲 Risk

🦅 H1B Visa Sponsor

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

📋 Description

• Analyze program results against operating plans and targets, investigate variances, and coordinate actions to address risks and opportunities • Develop and maintain dashboards, recurring reports, performance measures, and vendor scorecards • Validate data and metric definitions to ensure accurate, consistent, and useful reporting • Maintain program planning inputs and assumptions, track changes, and flag issues affecting projected results • Coordinate with Finance and Actuarial partners • Own initiatives from initial analysis through implementation and completion • Establish deliverables and milestones, coordinate stakeholders, track progress, address or escalate barriers, and confirm results • Plan and facilitate program performance and workstream meetings • Monitor vendor performance and deliverables, investigate variances, coordinate follow-up, and escalate unresolved issues • Support vendor evaluations and proof-of-concept initiatives • Monitor CMS and other regulatory developments, guidance, and deadlines • Partner with Analytics, Coding, Provider Engagement, Chart Retrieval, Actuarial, Compliance, and vendors • Prepare reports, presentations, and updates on program results, emerging issues, and recommendations • Improve reporting processes, workflows, and tracking tools

🎯 Requirements

• High School Diploma required • Bachelor’s degree in business administration, Economics, Finance, Health Care, Information Systems, Public Health, Statistics, Mathematics, or a related field • 3 years of healthcare industry work experience, or 6 years of relevant experience in lieu of degree • 2 years of Risk Adjustment Program or Operations work experience • Working knowledge of Medicare Advantage and ACA risk adjustment programs, operational processes, and payment methodologies • Understanding of performance measurement, data validation, and operational reporting • Working knowledge of financial concepts, including budgets, forecasts, and variance analysis • Familiarity with regulatory requirements and their implications for risk adjustment operations • Experience coordinating projects or workstreams involving multiple stakeholders and deadlines • Proficiency in Microsoft Office applications, including advanced Excel skills • Experience with Power BI or other business intelligence tools preferred • Ability to independently manage assignments and initiatives • Strong analytical, problem-solving, written, verbal communication, organization, documentation, and meeting facilitation skills • Ability to build effective working relationships and coordinate across internal departments and external vendors • Ability to work in an agile and dynamic environment • Ability to occasionally lift or move up to 5 pounds

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Retirement Plan • Paid Time Off • Holidays • Volunteer time off • Incentive Plan • Tuition Reimbursement • Flexible work environment • Training and continuing education • Community volunteering opportunities