• Risk Adjustment Reconciliation Specialist

    Location US-NY-New York
    Posted Date 1 week ago(11/7/2018 10:41 AM)
    Job ID
    # Positions
    ArchCare Community Services
    Experience (Years)
    Work Days Per Week
    Shift Start Time
    Shift End Time
    # Hours
  • Overview

    The Risk Adjustment Reconciliation Specialist is responsible for reviewing Medicare/Medicaid submissions and response reports for reconciliation of Encounter/Risk Adjustment data. 



    • Conduct analytical studies and audits against internal claim processing system to ensure reconciliation Risk Adjustment/ Encounter data submitted to CMS and NYS.
    • Assisting with monitoring the Encounter/Risk adjustment Data submissions, acceptance & error correction processes for both Medicare & Medicaid to meet with Risk Adjustment Federal & State regulations. Conduct research, investigation and correction of encounter submission data.
    • Develop and maintain detailed documentation that provides traceability for all regulatory data.
    • Document and present all findings to the Risk Adjustment Manager via report summaries.
    • Responsible for timely completion of special projects, including timeline development & maintenance as it pertains to Encounter Risk Adjustment Data submission.
    • Oversee the administration and Maintenance of Ability MD Online demographics for Facility, Provider and Member Eligibility data for encounter data entry. 
    • Assist with other corporate revenue reconciliation and will be liaison for HRA’s with Vendor for Community Population of the ArchCare Advantage Community program.




    ·        Current knowledge of managed care operations and best practices

    ·        Knowledge of government reimbursement policies, Risk Adjustment methodology, claims processing methodology, ICD-9, ICD-10 and CPT coding guidelines and knowledge State and Federal regulations.

    ·        Knowledge of 837 and (5010) data elements and specifications for electronic claim submissions

    ·        General managed care system knowledge – claims, enrollment, provider, care management

    ·        General knowledge of state and federal regulatory requirements related to plan operations

    ·        Excellent oral and written communication skills including the ability to communicate both simple and complex terms at different organizational levels.

    ·        Demonstrated ability to maintain exceptional data integrity.



    Additional Qualifications

    ·        Good judgment, problem solving and cognitive skills and an ability to process information accurately and in a timely manner

    ·        Working knowledge of local, state and federal regulations

    ·        Understanding of claims processing and how that impacts encounter files

    ·        Understanding of the impact of encounters and claims processing on financial statements, risk scores and dollars paid verses encounter files

    ·        Excellent writing skills

    ·        MS Office (MS Word, Excel and Access) skills are a must

    ·        HS Diploma; College Degree Preferred



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