EDI Analyst, Risk Adjustment

Company: Summa Health
Location: Akron
Posted on: February 23, 2021

Job Description:

Sr Recovery Analyst (Part C) / EDI Analyst, Risk Adjustment

SummaCare - 1200 E Market St, Akron OH

Full-Time / 40 Hours

Benefits

POSITION REQUIRED TO BE ONSITE (AKRON, OH) - NOT A REMOTE POSITION AT THIS TIME

SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating. SummaCare has also been recognized by U.S. News & World Report as being a Best Insurance Company for Medicare Advantage in 2020. Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.

Summary

Maintains, supports and reconciles Medicare (MC) claims, RAPS and encounter data before and after the data submission process to CMS in order to obtain the appropriate risk adjustment capitated payments per member per month from CMS. Creates needed databases and applications to support the submission and revenue reconciliation processes as well as informs management of all findings.

Educational Requirements
Bachelor Degree or may substitute with 4 years of like experience.

Required Experience

3+ years performing same or similar responsibilities. Relevant experience includes: in-depth working knowledge on recovering of Part C revenues. Experience with the following IT applications also required: working knowledge of Amisys, Crystal Report Writer, Microsoft Office Products, MS SQL Server applications, SQL, Query Analyzer, and Enterprise Manager.

Preferred Skills

A combination of the following: Working knowledge of FTP; utilization of a text Editor (UltraEdit/UltraCompare Preferred); SQL (building complex queries); stored procedures; DOS and BAT files; Relational Databases; Microsoft ACCESS - Form/query/report Design and VBA; All other MS Office Products; HIPAA EDI /EDPS; RAPS; CDAT; and CON XX RADV - including Batch uploads and reporting.

Required Licenses and/or Certificates
None required

Software and Data Entry Requirement
None

Skills And Abilities

Communication
Complex: ability to communicate complex information verbally and in written form that may include policies and procedures, financial, legal, and/or technical documents, and opinion papers; ability to provide guidance required to implement strategic programs and projects; ability to supervise work within and/or across departments; ability to negotiate and persuade professionals, board members, and general public.

Analytical
Highly Complex: designing, developing, implementing highly complex programs, products, technical systems, policies that affect overall direction of the company. Proofreading completed work to find and correct errors. Requires excellent attention to detail.

Other Skills And Abilities

• Maintain current knowledge of database management concepts, techniques and principles.
• Understands business processes and effectively translate business needs into appropriate data solutions.
• Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
• Demonstrate strong analytical ability and attention to detail.
• Organize and manage time to accurately complete tasks within designated time frames in fast-paced environment.
• Maintain current knowledge of and comply with company policies and procedures.
• Maintain confidentiality of patient and business information.
• Flexible: ability to adjust work hours to meet business demands.
  Physical Effort and Dexterity*
  
  • Sit for prolonged periods of time.
  • Bend, stoop, and stretch.
  • Lift up to 20 pounds.
  • Manual dexterity to operate computer, phone, and standard office machines.
    Visual Acuity, Hearing, and Speaking*
    
    • Candidates whose disabilities make them unable to meet these requirements will still be considered fully qualified if they can perform essential functions of job with reasonable accommodation.
      Scheduling
      Occasional overtime work required during peak business periods as scheduled by supervisor. Occasional travel that may require use of personal auto to attend meetings, conferences, workshops, and/or seminars.
      
      Safety Hazards and Environment
      Minimal hazards. General office working conditions.
      
      

Keywords: Summa Health, Akron , EDI Analyst, Risk Adjustment, Professions , Akron, Ohio