POSTED: May 29, 2025
POSITION: Risk Adjustment Analyst
DEPARTMENT: Finance
BASE RATE: $22.46 per hour, with potential for additional compensation based on qualifications.
POSITION SUMMARY:
The Risk Adjustment Analyst supports the Medicare and Medicaid risk adjustment programs. This position provides analytical support for risk adjustment initiatives and drives development and implementation of systems and processes to ensure risk scores appropriately reflect the disease burden of each member. The analyst collaborates internally with team members and externally with providers and vendors to ensure program objectives are achieved in compliance with all applicable laws and regulations.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Performs data analysis of member risk scores and the underlying data that drives risk score calculations.
3. Collaborates with the Risk Adjustment Program Manager to develop, implement, and continually refine prospective and retrospective diagnosis coding programs. Analyzes data flow and integrity to identify trends, opportunities for improvement, new strategies, and further program development.
4. Understands and advises on Centers for Medicare and Medicaid Services (CMS) and Michigan Department of Health and Human Services (MDHHS) risk score methodology, including risk score calculation, hierarchical condition categories (HCCs), and encounter data system (EDS) submissions and error resolution processes.
5. Coordinates the annual retrospective medical record review performed by external party.
6. Coordinates ongoing internal retrospective chart review including data analysis to identify charts for review, extraction of charts via remote Electronic Medical Record (EMR) access or faxed medical record request, collaboration with Risk Adjustment Compliance Coder on prioritization and performance of chart reviews, and coordination of resulting encounter data submission.
7. Collaborates with the Clinical Department on the integration of prospective program management processes and the coordination of risk adjustment gap and quality gap elimination initiatives.
8. Identifies and measures key performance indicators, return on investment, and risk score/revenue impact of risk adjustment initiatives.
9. Collaborates with risk adjustment software vendor and accounting staff in support of timely and accurate financial transactions and reporting. This includes, but is not limited to, providing analyses and reports to support estimates for mid-year and final risk adjustment revenue accruals and liabilities as well as current and future year revenue projections and budgets.
10. Collaborates with internal departments, as appropriate, to develop and oversee the execution of strategies, programs, and plans to engage contracted medical group physicians on HCC risk adjustment. Assists with provider education and training in proper assessment, coding, documentation, and data submission of member conditions.
11. Collaborates with internal departments, as appropriate, to develop and oversee the execution of strategies and programs to ensure integrity of diagnoses attributed to members submitted to MDHHS and CMS by UPHP.
12. Maintains a working knowledge of ICD-10 coding, claims, and provider data.
13. Stays informed about industry trends and best practices and utilizes this knowledge to refine and advance risk adjustment programs and foster a comprehensive understanding of risk adjustment policies and procedures within UPHP.
14. Maintains confidentiality of client data.
15. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Bachelor’s degree in a financial, information systems, or health related area; or combination of education and experience
Preferred:
Bachelor’s degree in Health Information Management
Certified Professional Coder certification
Experience:
Minimum:
Two (2) years in financial accounting or analysis, healthcare data analysis, or government
programs experience
Preferred:
Five (5) or more years of healthcare financial or data analysis experience; experience with
healthcare and risk adjustment data sources/processes and terminology (claims, CMS files,
ICD/CPT/HCPCS, HCCs, etc.); knowledge of Medicare or Medicaid payment methodologies
Required Skills:
Working knowledge of Microsoft Office (Word, Excel, Outlook)
Keyboarding proficiency
Excellent human relations, oral/written communication, and presentation skills
Excellent organizational and prioritization abilities
Strong analytical skills
Desired Skills:
Advanced skills in Microsoft Excel, including working with large data sets and utilizing advanced
functions and formulas
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
Working Conditions:
Works in office conditions, but occasional travel may be required
Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration
Subject to many interruptions
Occasionally subjected to irregular hours
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