Your Role

The Risk Adjustment Provider Partnership team provides essential support to all functions within the risk adjustment program, which includes interaction with various cross-functional teams within Blue Shield and contracted Provider Groups. The Risk Adjustment Consultant, Senior will report to the Manager, Risk Adjustment Provider Partnership. In this role, you will work with Provider Group leaders to improve recapture rates, understand clinical suspects, and ensure accurate documentation and coding. The Risk Adjustment Consultant, Senior will also implement Blue Shield Programs to meet CMS and risk adjustment coding guidelines and manage projects within the Risk Adjustment Provider Partnership team. The ideal candidate should have strong customer service skills, project management abilities, organizational skills, analytical skills, be self-motivated, and demonstrate high attention to detail.

Your Work

In this role, you will:

• Analyze information for core principles and functionality of decision, descriptive and predictive analytic methods including forecasting, statistical and machine learning techniques
• Train lower-level analysts on how to update and apply these advanced analytic techniques
• Contribute to successful programs for the team, engaged multiple areas related to vendor oversight, internal cross-functional partnerships, tracking performance and measuring results
• Lead data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
• Manage the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs and/or products
• Consult with provider groups to develop tailored plans aimed at enhancing their risk adjustment processes, boosting RAF performance, and improving coding specificity
• Assist provider groups in comprehending the various risk adjustment models, with a particular focus on the Medi-Cal CPDS+Rx model as it pertains to payment methodology. This includes guidance on claims and encounter submissions and the critical importance of accurate chart documentation for procedures and diagnosis coding
• Collaborate with Risk Adjustment Provider Partnership Management and Quality teams to formulate and implement comprehensive risk adjustment strategies
• Use analytics to identify training opportunities and collaborate with providers to clarify missing or inadequate information for determining appropriate diagnostic and procedure codes
• Collaborate with Analytics and internal departments for accurate monthly reports sent to Provider Groups
• Oversee internal administrative projects and manage the department inbox, addressing requests from Provider Groups and key internal departments

Your Knowledge and Experience

• Requires a bachelor's degree
• Requires at least 3 years of professional experience
• Requires knowledge of ICD-10, Risk Adjustment, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management and/or provider network management areas of a healthcare-related company
• Requires a minimum of 2 years experience facilitating meetings and presenting program education, metrics and results to external parties or internal leadership
• Requires an understanding of clinical metrics, claims/encounters and analytics
• Requires proficiency in Excel, Word, PowerPoint, and Outlook

Pay Range:

The pay range for this role is: $ 99000.00 to $ 148500.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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