Fallon Health

  • Risk Adjustment Analyst - Medicare Health Insurance.

    Location US-MA-Worcester
    Posted Date 3 days ago(1/14/2019 10:53 AM)
    Job ID
    # Positions
  • Overview

    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


    The primary role of the RAC will be to function as the Encounter SME for the Risk Adjustment & Analytics Department. The RAC maintains and operates the Encounter Data vendor software solutions and implements reporting specific to: Edge Server, RAPS, EDPS and Medicaid Encounter data submission analytic reports, as well as analyzes and researches all Encounter data errors and issues, collaborating with internal departments to work toward error resolution.


    The Risk Adjustment Consultant will be a SME for the respective risk adjustment model(s) and related Encounter Data submission requirements. The RAC will review and apply all related regulatory requirements to department activities for example: audits, changes in rate models, changes in submissions, audit responses and selection, etc. The RAC will use a combination of SAS, SQL, Risk Adjustment vendor software tools and other commonly used software, such as Excel, to establish an understanding and expertise for the assigned product line(s).


    The Risk Adjustment Consultant will be responsible for leading projects and engaging collaborating staff within Finance, IT, Care Services and Operational areas to optimize Risk Adjustment results. The RAC will interface with external and internal customers and vendors to identify and/or analyze business problems and develop solutions, as well as improve workflows and business processes to improve Risk Adjustment outcomes.

    The RAC will represent the Senior Director and department in corporate meetings. The RAC will represent the Risk Adjustment team, participating in corporate project workgroups and team initiatives as assigned. The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed.


    Analyze & Resolve Claims/ Encounter Data Errors

    • Encounter Data/Claims SME
    • Prioritize error resolution
    • Collaborate with internal departments to work toward error resolution
    • Manage Encounter Data software

    Product Line Support

    • Educate specified product line management on drivers of variances from budget for all revenue streams.
    • Meet regularly with the specified product manager(s) to identify and implement reports to improve revenue optimization efforts.

    Regulatory Compliance

    • Knowledgeable of data submission timelines and lags – RA factor impact
    • SME for regulatory rate release notes and summaries – review and oversee application of risk adjustment changes specific to Annual Rate Notices and interim rate bulletins from state and federal regulatory agencies.

    Corporate Project Support

    • Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as required.


    • BA or BS – Business Administration, Finance, Economics, Healthcare Administration, other
    • Experience working in Medicare, Medicaid and/or Merged Markets support role: Risk Adjustment, Regulatory, Enrollment, Internal Audit, Accounting, Underwriting, Marketing, Claims – other
    • Proficient/Advanced in Excel
    • Ability to create presentations & exhibits in formats that meet various audience levels
    • SQL- Navigator and/or SAS experience
    • ~7 years – Managed Care setting
    • ~5 years - Excel
    • ~3 years – SQL/SAS Experience




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