Health First Associate Risk Adjustment Analyst - HFHP, Full-Time in Rockledge, Florida

The Associate Risk Adjustment Analyst is responsible and accountable for providing Quality / No Harm, Customer Experience, and Stewardship by contributing to Health First Health Plans Risk Adjustment activities that support compliance with regulatory and contractual requirements specific to Medicare Advantage Plans. This individual will work with internal and external customers to ensure the integrity of all Health First Health Plans lines of business critically analyzing and identifying areas of operational improvement.

Primary Accountabilities * Assist in process improvements that will maximize risk adjustment factor increases and avoidance of inaccurate MA plan payments. Coordinate reconciliation efforts with contracted vendors. * Review of qualified medical records with documentation to include coding of ICD-9-CM codes to validate Risk Adjustment scores in the Medicare Advantage Plans. * Maintains national standards for ICD-9-CM coding guidelines including quantity and accuracy standards. * Ensure compliance with CMS regulations maintaining a process for the collection, submission and reconciliation of all data.
* Monitor and review all communication from federal and state authorities to identify and analyze revisions or new requirements to determine impact to strategy and first-level tactical planning. * Conduct chart audits in provider offices for the purpose of identifying and submitting documented diagnosis codes to the Centers for Medicare & Medicaid Services (CMS). * Maintain accurate historical records and comprehensive documentation of activities ensuring documents are compiled as needed to successfully meet requirements of federal agencies and stored according to established record retention policies. This includes modifications to meets CMS file requirements for submission of Risk Adjustment files. * Assist in coordinating and effectively communicating the health plan's position to regulators during all state and federal audits and site visits.

  • Bachelor’s degree in relevant field required; or 1- 3 years of related work experience.
  • Knowledge and understanding of Federal Medicare program, Medicare Advantage Plans, and the medical insurance industry in general.
  • Ability to read, analyze and interpret professional/legal/medical documents, policies and procedures, government regulations, legislative issues and legal documents.
  • Proficient in Microsoft Office products, including Word, Excel, Access, and PowerPoint. Microsoft Access preferred.
  • PAHM or other health care related certification (will be required during first year of employment).
  • Obtain nationally recognized coding certifications (required within one year of hire). Examples include: AAPC and AHIMA.
  • Requires reliable transportation and willingness to travel locally.

Job: *Health First Health Plans (Health Insurance)

Organization: *HF Administrative Plan Inc

Title: Associate Risk Adjustment Analyst - HFHP, Full-Time

Location: Florida - Brevard County-Rockledge

Requisition ID: 035344