About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose: 

The Risk Adjustment Analyst (RAA) will be a SME for the MassHealth risk adjustment model(s) and related data submission requirements. This role will be familiar with all revenue streams relevant to the product line(s) and will develop reporting to enhance efficiency of Fallon’s chart retrieval process. The RAA will support development and implementation of targeted member listings for chart reviews, in-home assessments, and outreach efforts across Fallon’s product lines. The RAA will also work with the Government Programs Actuary, product line management, Medical Economics and Care Services to provide analysis and recommendations to improve reporting and product performance. The RAA will represent the Risk Adjustment & Analytics team, participating in corporate project workgroups and team initiatives as assigned.

Primary Job Responsibilities: 

• Support management of departmental operations and performance dashboards and make recommendations to department leadership
• Support management of provider dashboards and make recommendations for performance improvement
• Attend meetings with Accountable Care Organiztions (ACOs) that Fallon Health shares risk with
• Routinely run reports and analysis for distribution to ACOs using the DxCG platform
• Compile and submit claims adjustments for supplemental submission from internal coding, external coding, and provider group coding initiatives
• Manage MassHealth/Medicaid and other governmental files intake and distribution
• Various ad-hoc analyses that may arise

Education:

BA or BS – Mathematics, Finance, Economics, Management, other

Experience:

• Intermediate to Advanced skill level with Microsoft Excel, Access and Power Point.
• Basic Data Warehouse knowledge and experience with Microsoft SQL
• Experience with SAS is plus.
• Strong communication and strong written skills
• Working knowledge of the provider-based healthcare industry, claims processing, provider billing or Risk Adjustment strongly preferred
• Familiarity with MassHealth/Medicaid a plus
• DxCG modeling platform experience a plus

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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