EmblemHealth is one of America’s largest not-for-profit health insurers, serving more than three million people in the New York tristate area. With an 80-year legacy of serving New York communities, EmblemHealth offers a full range of commercial and government-sponsored health plans to employers, individuals, and families.

We started back in the 1930s, at the height of the Great Depression. Out of hard times, the idea of health insurance was born — a system that would protect everyday people from financial misfortune if they had an accident or illness. Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 80 years, our purpose as a not-for-profit is still the same — to provide quality, affordable health insurance for New Yorkers and their families.

The EmblemHealth family of companies provides insurance plans, primary and specialty care, and wellness solutions. The family of companies covers the whole health journey, starting with affordable coverage through EmblemHealth, and ConnectiCare, a leading health plan in Connecticut. The family of companies also includes medicinal practices AdvantageCare Physicians and BronxDocs, occupational health clinic EmblemHealth Health@Work, EmblemHealth Family Dental, and WellSpark Health, a barrier-breaking digital wellness company.

As a family of companies with deep community roots, EmblemHealth Neighborhood Care and ConnectiCare Centers offer free wellness and community resources. Together, the family of companies creates healthier futures for customers and communities.

We think of ourselves as an 80-year-old start-up — big enough to offer the stability and benefits of a major corporation, with a ferocious commitment to innovation, collaboration, and flexibility. We believe in what we’re doing. And we’re looking for passionate people to join us.

Provide complex analytical and reporting/data mining support to the Risk Adjustment Department for Medicare, Medicaid and HIX products. Perform data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies. Must have strong Risk Adjustment experience/knowledge. Collaborate regularly with internal departments, including but not limited to: Finance, Medicare Operations, Network Management, Provider Contracting, and Health Economics, and external vendors on risk adjustment projects. Organize, prioritize, and manage various simultaneous tasks/projects to meet deadlines. Understand various areas of the business and operational processes relevant to the project’s goals. Provide technical support to leadership on prospective risk adjustment programs.

• Assist in performing analyses used in the development of financial plans, re-forecasts, and other financial projections.
• Work on identifying gaps in the claims, encounter reconciliation process, and provide insights to educate providers
• Build reports and dashboards to track risk adjustment related projects and to track the effectiveness of the initiatives.

Responsibilities

• Develop and maintain a sophisticated database where large volumes of data can be loaded, and information extracted for monthly dashboard reporting.
• Calculate ROI for risk adjustment vendors, initiatives and projects.
• Prepare complex monthly revenue valuation analysis, identifying & attributing proper credit to all initiatives.
• Produce trends month by month, year over year and other complex reports & analyses.
• Interact with business teams to gather the requirements and translate technical language.
• Map documents after the necessary data analysis.
• Lead meetings with internal technical teams on in office program solutions
• Provide analysis and recommendations for process improvements.
• Ensure accuracy of all monthly & supplemental data feed extracts.
• Liaise with IT and vendors' management teams on data issues & findings.
• Deliver projects, reports, updates, etc. on timely basis.
• Develop programs extracting specific claims details to create request files to FFS groups for wrap-around data.
• Clean & properly format files, ready for EH Submissions team.
• Produce ad hoc reports as requested.
• Participate in special projects; and perform related duties as assigned.

Qualifications

• Bachelor’s Degree in Finance, Health Care Management or related field (Required)
• 4 – 6+ years of relevant, professional working experience including experience with Information Management/Analysis within a Healthcare environment, preferably within the payer provider contracting or utilization management area (Required)
• Proficiency with MS Office (Word, Excel, PowerPoint, Outlook); strong SAS, Access and Oracle database skills (Required)
• Ability to effectively calculate and communicate forecasts/projections (Required)
• Proven track record of successfully managing multiple tasks/projects with competing deadlines (Required)
• Strong communication skills (verbal, written, presentation, interpersonal) with all levels/types of audiences (Required)
• Working knowledge of CPT, RBRVS, ICD codes and CMS-HCC Risk Adjustment Payment Methodology (Required)