Risk Adjustment Claims Analyst

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The Risk Adjustment Claims Analyst will be responsible for identifying, interpreting, auditing and analyzing various encounter data and identifying areas of opportunity as it relates to claims processing and encounter submission. They may be required to prepare supplemental drill down or visual aids (charts, graphs) or summaries to assist with explanation of the findings. The Risk Adjustment Claims Analyst will interpret the needs of the department and will serve as the SME on encounter Scrubs or Business rules logic changes or requests that impact encounter data. This position will be accountable for providing root cause analysis of all claims encounter errors related to the Medicare, Medicaid, Child Health Plus, Essential Plan, HARP, Commercial Off-Exchange, Medicare Off-Exchange and Commercial On-Exchange product lines and will work collaboratively with Provider Registry, Claim Operations, Finance, IT, and Enrollment and Billing.

Qualifications:

• Associates degree or two (2) years of equivalent experience required; Associate's degree in accounting, finance, business administration, mathematics, statistics or related discipline is preferred.
• Minimum three (3) years claims/analytical experience in Health Care Industry, indemnity insurer or similar insurance environment is required.
• Proficiency in Claims processing specifically within a Facets environment is required.
• Proficiency in Microsoft Office (Word and Excel) and MS Access required.
• Knowledge of ICD-10 diagnosis and procedure codes, CPT codes, Revenue codes, and HCPCS codes is required.
• Experience with Medicare, Medicaid and Commercial programs is preferred.
• Prior leadership and/or project management experience is preferred.
• Knowledge of medical terminology, anatomy and physiology, and medical chart review preferred.
• Demonstrated ability to participate in projects/initiatives that are claims or claims auditing related.
• Demonstrated ability to prioritize work among multiple tasks and projects.
• Demonstrated ability to work independently and as part of a team.
• Demonstrated ability to research issues, perform root-cause analysis, compare/contrast, and implement problem resolution.
• Excellent organizational and planning skills.
• Demonstrated ability to pro-actively identify problems, as well as recommend and/or implement effective solutions.
• Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
• Demonstrated ability to work with and maintain confidential information.
• Excellent verbal and written communication skills.
• Flexibility to adapt to a changing and fast-paced environment.

CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.

CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at https://www.cdphp.com/about-us/jobs/benefits.

As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.