Business Analyst - Risk Adjustment
Grand Rapids, MI
Contracted
Mid Level
Risk Adjustment Business Analyst with strong expertise in CMS regulations, Medicare Advantage, and compliance-driven program execution. The ideal candidate will combine regulatory knowledge, data analysis, and process improvement skills to enhance risk adjustment accuracy, ensure compliance, and drive operational efficiency.
- They research, interpret and understand CMS regulations and applicable laws pertaining to risk adjustment
- They collaborate with stakeholders to gather and document business requirements for risk adjustment programs, translating them into functional specifications for business teams.
- Risk Management
- They develop and implement risk assessment and monitoring review processes to mitigate and/or remediate risk within the risk adjustment space.
- They track and manage corrective action plans to address identified compliance risks and deficiencies
- Process Improvement:
- They analyze existing controls and processes against guidance to enhance and strengthen those processes and controls in alignment with current guidance and best practices.
- They support the documentation, implementation and tracking of controls and systems which create enhanced efficiency and effectiveness.
Required Skills/Experience – The rest of the required skills/experience. Include:
- Technical Skills:
- Data Analysis: Ability to analyze large datasets to identify trends, patterns, and anomalies related to risk adjustment and compliance. This includes:
- Using data analysis tools and software.
- Interpreting data to understand risk adjustment and compliance issues.
- Business Intelligence (BI) and Reporting: Experience with BI tools and reporting platforms to create dashboards and reports for monitoring risk adjustment performance and compliance.
- Proficiency in MS Office applications
- Data Analysis: Ability to analyze large datasets to identify trends, patterns, and anomalies related to risk adjustment and compliance. This includes:
- Business Skills:
- Risk Adjustment Program Knowledge: Understanding of relevant risk adjustment programs, such as Medicare Advantage, and their specific compliance requirements.
- Regulatory Compliance: Knowledge of healthcare regulations and laws, including HIPAA, and how they apply to risk adjustment data and processes.
- Business Process Analysis: Ability to analyze existing business processes, identify inefficiencies, and recommend improvements to enhance compliance and performance.
- Problem-solving: Ability to identify and assist with resolving complex compliance issues related to risk adjustment data and processes.
- Communication: Excellent verbal and written communication skills to effectively communicate with internal teams, external partners, and regulatory bodies.
- Attention to Detail: Meticulous attention to detail to ensure accuracy and compliance in data and processes.
- Research: Ability to review conduct research and review of regulatory guidance to interpret and implement.
- Project Management: Ability to manage projects related to risk adjustment initiatives and compliance projects, requiring skills like defining scope, identifying resources, and scheduling.
- Stakeholder Management: Ability to collaborate effectively with various stakeholders, including clinical staff, IT teams, and management.
- Critical Thinking and Decision-Making: Ability to analyze situations, make informed decisions, and develop solutions to complex problems.
- Adaptability: Ability to adapt to changes in regulations and risk adjustment programs.
Preferred Skills/Experience – Optional but preferred skills/experience. Include:
- Prior roles in a compliance and/or regulatory department
Education/Certifications – Include:
- Bachelor’s degree in healthcare administration, business, or a related field with strong quantitative and analytical coursework
- Compliance related certification, e.g., CHC, CCP would be a plus, not required
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