Description
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.6 million Ohioans through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans.
Medical Mutual' s status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us and help our members achieve their best possible health and quality of life.
Risk Adjustment Programs Analyst I
Under direct supervision, responsible for the flow of data that results from Risk Adjustment Programs. Analyzes data gaps that may exist within file transfers. Makes actionable recommendations on solutions for data gaps and takes the initiative to complete solutions.
Risk Adjustment Programs Analyst II
Under general supervision, maintains reporting tools that monitor the data flow that results from Risk Adjustment Programs. Analyzes the impact that may occur from data gaps. Collaborates with teammates to implement solutions for any data gap occurrence. Performs population comparison analysis to evaluate impact Risk Adjustment Programs have on different demographic segments.
Risk Adjustment Programs Analyst III
Under general supervision, analyzes risk adjustment trends and opportunities. Evaluates the impact risk adjustment programming has on membership including, but not limited to risk score optimization, revenue, population comparison, satisfaction, and retention. Identifies process improvements and opportunities to achieve efficiency and effectiveness. Uses metrics to measure improvements and evaluate changes in processes.
Sr. Risk Adjustment Programs Analyst
Under limited supervision, serves as a primary liaison between all areas of the RAPs department including Information Services, Chart Retrieval, Medical Coding and Analytics. Supports the complete and accurate capture of conditions for members enrolled in government programs, ensuring the Company receives the appropriate reimbursement to help cover the conditions of enrollees. Identifies, analyzes and solves issues ranging from technical to analytical. Analyzes the impact of RAPs and identifies process improvements and opportunities to achieve efficiency and effectiveness. Uses metrics to measure improvements and evaluate changes in processes.
Responsibilities
Risk Adjustment Programs Analyst I
- Gathers, formats, and submits data to internal and external partners to help improve risk score accuracy
- Assists in the tracking and reconciliation of risk adjustment data at each phase of a project
- Analyzes risk adjustment data to help evaluate RAPS programs
- Collaborates with internal risk adjustment operations and external vendor partners to help improve efficiencies
- Maintains current industry knowledge and stays abreast of best practices
- Assists in the maintenance of departmental policies and procedures/workflows
- Performs other duties as assigned
Risk Adjustment Programs Analyst II
- Tracks and reconciles risk adjustment data between internal risk adjustment operations and external vendor partners to ensure there are no data gaps
- Analyzes impact of reconciliation process and identifies solutions with reconciled data
- Maintains and updates databases and spreadsheets according to changing business needs
- Creates project management reporting to evaluate completion and timeliness of projects
- Analyzes and compares different populations within risk adjustment lines of business
- Collaborates with internal risk adjustment operations and external vendor partners to help improve efficiencies
- Maintains current industry knowledge and stays abreast of best practices
- Assists in the maintenance of departmental policies and procedures/workflows
- Performs other duties as assigned
Risk Adjustment Programs Analyst III
- Analyzes the Company's performance on risk scoring and underlying key indicators using risk analytics applications and other key reporting tools
- Analyzes trends, identifies opportunities for improvement, and supports initiatives aimed at improving efficiency, effectiveness and outcomes of RAPs
- Analyzes and compares different populations within risk adjustment lines of business
- Supports revenue analysis and projections of RAPs
- Collaborates with internal risk adjustment operations and external vendor partners to help improve efficiencies
- Maintains current industry knowledge and stays abreast of best practices. Orients, trains and assists more junior level staff as needed.
- Creates and maintains departmental policies and procedures/workflows
- Performs other duties as assigned
Sr. Risk Adjustment Programs Analyst
- Analyzes trends, identifies opportunities for improvement, and develops initiatives aimed at improving efficiency, effectiveness and outcomes of RAPs
- Tracks and prioritizes projects and identifies metrics to assess program processes projects
- Applies advanced analytic and mining techniques to enhance existing or develop new clinical algorithms and/or predictive models to target program outreach, detect member and/or provider behavior patterns, and profile members and/or providers for development of effective member and provider engagement strategies
- Analyzes the Company's performance on risk scoring and underlying key indicators using risk analytics applications and other key reporting tools
- Maintains current industry knowledge and stays abreast of best practices. Orients, trains and assists more junior level Analysts. May supervise staff in the absence of management
- Supports revenue analysis and projections of RAPs
- Analyzes regulatory and competitive market information related to both ACA and Medicare Advantage risk models to determine impact on risk adjustment programs and their effectiveness, advises on necessary courses of action
- Collaborates and communicates with leadership from RAPs, Care Management, Quality and Population Health, Provider Engagement and Contracting, and other internal and external stakeholders to define, develop, evaluate, and enhance member and provider directed programs
- Creates and maintains departmental policies and procedures/workflows
- Performs other duties as assigned.
Qualifications
Qualifications
Risk Adjustment Programs Analyst I
Education and Experience:
- Bachelor's degree in Business or Healthcare Administration, Finance or related field
- Analytical experience in managed care, health care, risk adjustment or Medicare/Medicaid preferred
Technical Skills and Knowledge:
- Knowledge of project management processes and tools
- Intermediate Microsoft Office and database querying skills (SQL and/or SAS)
- Basic understanding of health care delivery system and operational processes and requirements to support a health insurance product line.
- Knowledge of data flow processes and principles
- Understanding of file transfer protocols
Risk Adjustment Programs Analyst II
Education and Experience:
- Bachelor's degree in Business or Healthcare Administration, Finance or related field
- 2 year's experience as a RAPs Analyst or equivalent analytical and systems/project management experience in managed care, health care, risk adjustment or Medicare/Medicaid
Technical Skills and Knowledge:
- Knowledge of project management processes and tools
- Intermediate statistical analysis, Microsoft Office, and database reporting skills (SQL and/or SAS)
- Basic knowledge of Affordable Care Act (ACA) and Medicare Advantage (MA) Hierarchical Condition Category Risk Adjustment models
- Basic understanding of health care delivery system and operational processes and requirements to support a health insurance product line
- Familiarity with health plan activities with emphasis on ACA and MA Risk Adjustment models and programs
Risk Adjustment Programs Analyst III
Education and Experience:
- Bachelor's degree in Business or Healthcare Administration, Finance or related field.
- 3 years progressive experience as a RAPs Analyst or equivalent analytical and systems/project management experience in managed care, health care, risk adjustment or Medicare/Medicaid.
Technical Skills and Knowledge:
- Knowledge of project management processes and tools
- Intermediate to advanced statistical analysis, Microsoft Office, and database reporting skills (SQL and/or SAS)
- Knowledge of Affordable Care Act (ACA) and Medicare Advantage (MA) Hierarchical Condition Category (HCC) Risk Adjustment models
- Understanding of health care delivery system and operational processes and requirements to support a health insurance product line.
- Knowledge of health plan activities with emphasis on ACA and MA Risk Adjustment models and programs
- Knowledge of, and the ability to apply medical and risk adjustment coding concepts.
Sr. Risk Adjustment Programs Analyst
Education and Experience:
- Bachelor's degree in Business or Healthcare Administration, Finance or related field
- 5 years progressive experience as a RAPs Analyst or equivalent analytical and systems/project management experience in managed care, health care, risk adjustment or Medicare/Medicaid.
Technical Skills and Knowledge:
- Comprehensive knowledge of health plan activities with emphasis on ACA and Medicare Advantage Risk Adjustment models and programs
- Knowledge of Affordable Care Act (ACA) and Medicare Advantage (MA) Hierarchical Condition Category (HCC) Risk Adjustment models
- Knowledge of project management processes and tools
- Understanding of health care delivery system and operational processes and requirements to support a health insurance product line
- Advanced statistical analysis, Microsoft Office and database reporting (SQL and/or SAS) skills
- Strong knowledge of, and the ability to apply medical and risk adjustment coding concepts
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- Top Workplace in Northeast Ohio. Year after year we've received this recognition!
- On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!
- On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
- Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
- Business Casual attire
Excellent Benefits and Compensation:
- Competitive compensation plans
- Employee bonus program
- 401(k) with company match and an additional company contribution
- Excellent medical, dental, vision, and disability insurance
An Investment in You:
- Career development programs and classes
- Mentoring and coaching to help you advance
- Education reimbursement up to $5K per year
About Medical Mutual:
We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!
At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
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