New

Risk Adjustment Analyst II - Hybrid

Blue Cross Blue Shield of Arizona
United States, Arizona, Phoenix
Jul 01, 2025
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This position is hybrid within the state of AZ only.This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Perform data extraction, analytical model development and maintenance, preparation of risk adjustment data for CMS, medical record retrieval, risk gap closure tactics, and all risk adjustment data validation audit requirements. REQUIRED QUALIFICATIONS Required Work Experience 3 years of experience working for a healthcare organization / health insurer (Applies to Level 2 and 3) 3 years of experience in an actuarial, healthcare economics, or similar analytic field (Applies to Levels 2 and 3) Required Education Bachelor's Degree in business, mathematics, statistics, or related field of study (Applies to All Levels) Required Licenses N/A Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience 2 years of experience in an actuarial, healthcare economics, or similar analytic field (Applies to Level 1) 5 years of experience working for a healthcare organization / health insurer (Applies to Levels 2 and 3) 5 years of experience in an actuarial, healthcare economics, or similar analytic field (Applies to Levels 2 and 3) Preferred Education Master's Degree in business, mathematics, statistics, or related field of study. (Applies to All Levels) Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Level 1 Evaluate and maintain SAS code to generate XML files transferred to and received from CMS and external vendors used to calculate and monitor risk scores and condition prevalence. Perform analyses on potential impacts of membership models and market composition on risk position of BCBSAZ. Evaluate, design, and implement risk adjustment capture and improvement programs with the goal of receiving and capturing appropriate intensity and persistency of diagnostic information for our members. Maintain current risk adjustment business rules and control documents, updating code as necessary based on CMS changes and updates. Monitor CMS Edge Server error reporting, and assist in the triage and correction of errors. Represent BCBSAZ on both CMS and Association calls on Risk Adjustment, Reinsurance, and Edge Server topics. Develop monthly Risk Adjustment Key Performance Indicator analysis using Edge Server and external vendor data. Serve as team member for annual RADV audit, working with auditor to obtain all required files and documentation. Monitor and maintain member mastering process, identifying issues and suggesting improvements to the mastering algorithm. Develop medical chart retrieval list for RADV audit, as well as supplemental risk gap closure tactics. Create, modify, and maintain SAS programming associated with specific responsibilities/analyses. Interpret, communicate, and present results to all levels of management in consistent and easy to understand formats to facilitate fact-based decision making. Serve as an internal consultant to define business questions and transform data and analysis into meaningful and actionable information for a variety of customer segments. Build and maintain close working relationships with internal stakeholders (Provider Network Management, Health Services, Actuarial, Sales, Inter-plan Programs, Business Informatics, IT, Finance) and key external client contacts (Providers, Vendors, Brokers, BCBS Association, Blues Plans, Auditors). Level 2 Report to a supervisor or manager who provides general supervisory instructions, manages projects and reviews results. Develops own work-plans, and discusses timelines, prioritization, and objectives with supervisor or manager. Provide self- and peer-review of job responsibilities listed above. Develop and maintain computer programs to support analyses. Identify and implement potential improvements to existing programming and reporting that support analyses and processes. Make sound assumptions and discuss with supervisor, manager, or project manager. Complete projects within preset timelines and report status to supervisor and project manager. Prepare written documentation on projects to provide a peer review trail and ensure continuity and integrity. Communicate results and recommendations to internal and external customers. Share knowledge of skills, projects, and business needs with peers and less-experienced analysts. Train new analysts. Level 3 Report to a supervisor or manager who provides minimal supervisory instructions, limited project management, and minimal or limited review of results, beyond pre-release peer review. Plan and lead complex projects from inception to completion. Includes working independently on creating timelines, working with other areas to define deliverables, monitoring progress, implementing the project and resolving/monitoring post-implementation issues. Communicate (both verbally and in writing) and interprets results, recommendations and abstract concepts to internal and external customers. Anticipate and addresses possible customer questions and concerns. Perform and interpret complex calculations related to the specific job responsibilities. Incorporate strategic planning in all areas of responsibility. Train and mentor other analysts. ALL LEVELS Each progressive level includes the ability to perform the essential functions of any lower levels and mentor employees in those levels. The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. REQUIRED COMPETENCIES Required Job Skills (Applies to All Levels) Intermediate skill in use of office equipment, including copiers, fax machines, scanners and telephones Intermediate PC proficiency Intermediate proficiency in database, presentation, and word processing software Expert proficiency in spreadsheet software Intermediate proficiency in computer programming, including SAS and other business intelligence programs Advanced skill in mathematics and statistics Required Professional Competencies (Applies to All Levels) Broad understanding of health insurance terms and concepts General knowledge of the healthcare industry Knowledge of health benefit design and rating techniques Analytical knowledge necessary to generate reports based on available data and then make sound decisions based on reported data Ability to solve problems independently and draw accurate conclusions from limited data using basic mathematical modeling and actuarial techniques. Ability to deal with ambiguity and make recommendations with less than complete or conflicting information while maintaining appropriate time management. Ability to maintain confidentiality and privacy Ability to communicate effectively, both orally and in writing, to all levels in all departments. Ability to build and maintain productive working relationships with others. Skill in prioritizing tasks and working with multiple priorities, sometimes under limited time constraints Ability to summarize technical information to a non-technical audience. Proactive about requesting enough information to fully understand and meet the business need. Required Leadership Experience and Competencies (Applies to All Levels) N/A PREFERRED COMPETENCIES Preferred Job Skills (Applies to All Levels) Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones Advanced PC proficiency Advanced proficiency in spreadsheet, database and word processing software Intermediate proficiency with data warehouses and query tools / design Preferred Professional Competencies (Applies to All Levels) Knowledge of funding arrangements and their ratings Project management skill needed to create timelines, track deliverables and progress, resolve issues, and communicate project status Preferred Leadership Experience and Competencies (Applies to All Levels) N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.