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