What are the responsibilities and job description for the Risk Adjustment Consulting, Associate position at Blue Shield of California?
Your Role
The Risk Adjustment Consulting, Associate will report to the Medi-Cal Encounter Submissions Manager. In this role you will provide essential support to all functions within the team including: (1) Encounter data submissions for all lines of businesses in accordance with regulatory requirements and contracts provisions. (2) Provide business logic and verify system processes are in line with the given business rules. (3) Support various projects to completion ensuring timely and accurate implementation. (4) Optimize existing processes to support department priorities.
Your Work
In this role, you will:
- Actively learning the core principles of decision analytics with knowledge of the analytic tools and techniques that are used to acquire and analyze data for reporting and decision making
- Understand, update, and run programs that applies to decision analytic techniques
- Understand claim, premium, membership and/or risk score assignment data at a basic level
- Compile and categorize data, documenting and verifying the factors used in computations such as those used in premiums, benefits, member risk data and score submissions
- Participate in the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs and/or products
- Have oversight of daily encounter data operations, including end-to-end monitoring and reconciliation of regulatory submissions
- Analyze, report submission trends, monitor KPIs, perform root cause analysis and provide solutions to encounter data submission quality, volumes and timeliness measures
- Work with various stakeholders and industry experts to stay current with regulatory reporting requirements and implement best-in-class submission practices and requirements optimize the processes and submissions
- Ensure workflow procedures and guidelines are clearly documented, communicated and followed
- Support all functions in the department to align with the enterprise priorities and goals. This may include ad-hoc requests and reporting associated with encounter data.
Your Knowledge and Experience
- Requires a bachelor’s degree or equivalent experience
- Requires excellent interpersonal, verbal, and written communication and presentation skills – especially presentations of complex, technical information to non-technical audiences and from non-technical information to technical information
- Required experience with SQL / SAS / Tableau and other data/analytic tools
- Desired experience in healthcare management and state and federal regulatory data standards and requirements Desired experience with data reconciliation, control reports and EDI transactions specifically 837P, 837I, 837D, 277CA, and 999
Pay Range:
The pay range for this role is: $ 32.08 to $ 44.90 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
Our Values:
- Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:
At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
Member-facing and approved out-of-state roles remain remote.
Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Salary : $32 - $45
