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Senior Data Analyst - Risk Adjusment

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POST DATE 10/10/2017
END DATE 12/14/2017

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Under the supervision of the Manager, Data and Reporting, this individual will be responsible for supporting critical data reporting functions for Enterprise Risk Adjustment Department (ERAD) including risk adjustment submissions to CMS, state agencies, internal data reconciliations, data transfer between THP (Tufts Health Plan) and risk adjustment program vendors / provider groups. This individual should be exceptionally strong analytically, demonstrate high levels of professionalism, willingness to learn and strong communication skills. This individual should have the ability to synthesize large data sets, complex information and work effectively across business areas including member operations, provider contracting and claims, information technology and actuarial. This person should demonstrate an ability to follow business processes, to consider options when problems arise, and to identify and escalate issues appropriately. The following description details the scope of this person's roles and responsibilities.


Data Submission Integrity
* Monitor ongoing encounter data submissions and corresponding federal or state government agency responses files to identify and address any file level discrepancies in a timely manner.
* Perform routine data reconciliations to ensure data submission integrity. Run monthly dashboards to effectively track acceptance rates and submission trends.
* Review monthly error reports, perform trend analysis, investigate critical errors and work with the appropriate business area on resolution.
* Enhance/improve and automate existing reconciliation and reporting code using advance SAS skills
* Interface with IT for implementation of enhancements and timely resolution of production issues pertaining to CMS and EOHHS risk adjustment data submission, including issue investigation, business requirements, user acceptance testing and post implementation monitoring.
* Collaborate with internal stakeholders including THP claims and member operations and information technology to ensure that the process enhancements and mechanisms are maintained and monitored to ensure complete and accurate data is provided to our RAPS vendor and CMS (via either RAPS or EDPS submissions).
* Support direct provider to THP file submission processes (referred to internally as Alternative Submission Method files) to ensure that a complete diagnostic profile is submitted to Tufts HP, passes our internal SAS data validation processes and is subsequently delivered to CMS in a timely manner.
* Stay informed on CMS risk adjustment updates, determine impact to existing processes and recommend modifications to THP's risk adjustment reporting as applicable.
* Support the domain leads across a range of activities including monthly encounter data submission process to the Massachusetts Executive Office of Health and Human Services (specifically MassHealth), EDGE Server Submissions and CMS Medicare Advantage Submissions

Reporting and Data Management
* Use Cognos or Business Object to create monthly submission dashboard and run submission reconciliation
* Use SAS to create Adhoc reports from multiple sources
* Assist with the implementation of new program vendors regarding data file transfers, reviews internally received files for completeness reasonability and accuracy.
* Support operational reporting performed by the vendor / vendor management staff within ERAD and reviews for completeness and accuracy.
* Run the inter-coder reliability, productivity and results reporting for QA.
* Support the infrastructure for the Quality Assurance (QA) access database application, including data load, maintenance, upgrades and coder assignment as needed.
* Management and SAS coding support associated with the deployment of THP's home-grown Quality Assurance algorithms as needed.

* Conduct ad hoc analyses specific to risk score trends, data/claims submissions and program performance to support risk adjustment analytics and also deliver timely and accurate information to contracted provider groups.
* Maintain ICD-10 early warning system to monitor and conducts routine analyses / reporting to track trends and patterns in diagnosis coding following the implementation of ICD-10.
* Perform data analytics to support ongoing and upcoming risk adjustment initiatives.
Collaboration with Internal / External Stakeholders
* Collaborate effectively with data owners and function leads in ERAD, THP's member operations, provider information, claims and IT.
* Collaborate with federal agencies, vendor data management staff, and industry trade associations to remain up-to-date with changes and updates from CMS and EOHHS.

EDUCATION: (Minimum education & certifications required)
Bachelor's degree required; graduate degree preferred; background in health informatics, business analysis programming, IT, business administration, finance, quantitative techniques or a related discipline.

EXPERIENCE: (Years of experience)
3-5 years of experience in progressively responsible analytical data management roles in a complex operational setting or consulting role. Previous experience working in the health care / health insurance sector either for a health plan, provider group, healthcare IT / management consultancy or auditing firm. Understanding of claims systems and processing and Medicare Advantage, EDGE server submission, EDI files, RAPS, EDPS and/or experience working with large data sets, CMS, health insurers and/or medical providers in a technical capacity preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)
* Expertise in data management and controls, IT processes, and utilizing analytical tools. Comfortable working with large data sets from disparate sources, and able to identify relevant patterns and trends.
* Experience with applicable software, database programs and reporting tools such as: Cognos, SAS (Base SAS / SAS Enterprise), Data Architectural Design, SQL, SPSS, Microsoft Access, and Visual Basic Programming. (SAS certification preferred).
* Proficient in Microsoft Excel, PowerPoint and Word.
* Experience with developing detailed documentation of policies and procedures for analytic functions.
* Highly energetic, organized, detail-oriented, resourceful and self-motivated.
* Excellent project management skills with a proven ability to prioritize tasks and follow through to completion.
* Strong critical thinking skills, with professional growth potential preferred.
* Must possess maturity, a high degree of professionalism and be able to deal with complexity and uncertainty and/or business decision ambiguity in the face of incomplete information.
* Strong interpersonal and communication skills with an ability to work collaboratively with both internal and external stakeholders.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
* Must be able to excel in a fast paced business environment and handle multiple priorities. Must be highly effective in both written and oral communication
* Must be able to exercise appropriate judgment when making decisions
* Must be able to work in excess of 40 hours per work as the job may require, including evenings and weekends

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.