Senior Analyst, Risk Adjustment Data Integrity – Payor Submissions

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Become a part of the Integrated Kidney Care Model of Care team and contribute to the Comprehensive Health Evaluation program.

• Emphasize encounter data submissions and enhance the execution of intricate payor submissions.

• Enhance data integrity while adhering to CMS encounter reconciliation deadlines.

• Manage high-volume complex data files across various health plan templates.

• Format pipe- and tilde-delimited files, ensuring the accuracy of Tax IDs, member identifiers, and ICD-10 codes.

• Independently oversee the Alternate Submission Methodology sweeps calendar, CMS deadline operations, and sFTP transmissions.

• Act as the main operational liaison among Team Helix, Gemini/TopLine, ROPS, IT, and external payor risk adjustment teams.

⛳️ Requirements

• A Bachelor’s degree in Healthcare Administration, Health Informatics, Data Analytics, Finance, Computer Science, Business, or a related field, or equivalent practical experience.

• 2–4+ years of pertinent experience in healthcare data analysis, claims operations, risk adjustment, or billing/EDI operations.

• Proficiency in advanced Excel, including complex formulas, nested logic, text manipulation, pivot tables, and creating pipe- and tilde-delimited text files.

• Working knowledge of SQL and relational database structures.

• Practical experience with sFTP and secure health plan web portals.

• Familiarity with EHR and Practice Management platforms such as NextGen, Cerner, or Epic.

• Understanding of CMS Risk Adjustment concepts, HCCs, and CMS sweeps/submission cycles.

• Familiarity with EDI 837 encounter files, 835 payment/remittance files, 999 acknowledgments, and CMS MAO-004 response files.

• Capability to conduct root-cause analysis on claim denials and data discrepancies, along with managing unbilled/rebill workflows.

• Preferred: experience with a Medicare Advantage health plan, MSO, or value-based clinical organization.

• Preferred: RHIA or RHIT certification.

• Preferred: experience with Tableau or Power BI.

• Preferred: experience in supporting EHR or data platform migrations.

🏝️ Benefits

• 401k match.

• Healthcare coverage.

• A wide range of additional benefits.

• Commitment to equal opportunity in the workplace.

• Affirmative action protections.