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Risk Adjustment Consulting, Consultant

Company: Blue Shield of California
Location: Oakland
Posted on: June 6, 2021

Job Description:

Job Summary

The Risk Adjustment Provider Program Consultant provides essential support to all functions within the risk adjustment program, which includes interaction with various cross-functional teams within Blue Shield and Provider Groups. This person is responsible for providing expertise in risk adjustment for our providers. The Risk Adjustment Provider Program Consultant will interface with Provider Group operational and clinical leadership to assist in identification of operational and clinical practices in maximizing recapture rates, understanding clinical suspects, and monitoring of appropriate clinical documentation and accurate coding. The Risk Adjustment Provider Program Consultant will also coordinate implementation of Blue Shield Programs designed to ensure all diagnoses are coded according to CMS and risk adjustment coding guidelines. The ideal candidate possesses excellent customer service skills, project management skills, organizational skill, analytic skill, self-starter, and high attention to detail. May be responsible for assembling a project team, assigning, and monitoring work of team members and providing guidance and leadership. May be responsible for assembling a project team, assigning, and monitoring work of team members and providing guidance and leadership.


  • Consult with Provider Groups to drive improvements in support of their risk adjustment processes through developing comprehensive, provider specific plans to increase their RAF performance and improved their coding specificity.
  • Assisting Provider Groups in understanding the CMS-HCC Risk Adjustment as it relates to payment methodology through their claims/encounter submissions and the importance of proper chart documentation of procedures and diagnoses coding.
  • Assist Provider Groups in understanding Medicare Stars quality and incentive programs utilizing analytics and identifies and target providers.
  • Establish positive, long-term, consultative relationship with Providers.
  • Utilize analytics and identifies targeted providers for Medicare Risk Adjustment training and programs through routinely consulting with Providers to clarify missing or inadequate information to determine appropriate diagnostic and procedure codes.
  • Implementation of clinical education materials and initiatives related to risk adjustment activities, HEDIS measures, and any appropriate gaps of care.
  • Ensure member encounter data submissions (services and disease conditions) are being accurately documented and relevant procedure codes as well as all relevant diagnosis codes are captured through encounter and claims data.
  • Reviews analysis to forecast and evaluate the performance of the BSC Risk Adjustment Programs and refine annul risk adjustment strategies to achieve optimal performance.
  • Performs analysis and provides formal feedback to Provider Groups on regularly scheduled basis through developing and delivering materials, coding tools and actionable reporting.
  • Manage provider engagement relationship with measurable, actionable, solutions to Provider Groups that will result in improved documentation accuracy and submission practices.
  • Assist in collecting charts where necessary for analysis.
  • Collaborates with providers, coders, facility staff and a variety of internal and external personnel on wide scope of Risk Adjustment and Quality education efforts.
  • Communication to external parties and/or leadership to present financial/clinical metrics and facilitate their engagement in programs.
  • End-to-end cross-functional project management.
  • Knowledgeable about healthcare-related governmental regulations, procedures, and requirements. Continuous learning as additional information is released.
  • Special project as assigned.
  • Some travel required.

Knowledge and Experience

  • Requires a minimum of 6 to 7 years of professional experience.
  • Requires minimum of a bachelor's degree in Healthcare Administration, Business Administration, Master's Degree preferred.
  • Requires healthcare industry experience, with a thorough understanding of clinical metrics, claims/encounters, and analytics.
  • Knowledge of ICD-10, Risk Adjustment, ICD-10, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management and/or provider network management areas of a healthcare-related company.
  • Experience facilitating meetings and presenting program education, metrics and results to external parties or internal leadership.
  • Experience developing analytic reporting analytic insights into RAF improvement and business/financial challenges.
  • Proficient in Excel, Word, PowerPoint, and Outlook.
  • Excellent interpersonal/communication skills across various mediums (written, verbally in meetings and over-the-phone).
  • The ability to drive/engage others outside the team to successfully complete projects.
  • Healthcare background, particularly knowledge of the Medicare Market highly preferred.
  • The desire to help our team, Blue Shield, and our members.
  • The ability to manage projects/timelines to achieve successful outcomes.
  • Technical/analytic skills.

Additional Information

  • About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
  • 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.

Please click here for further physical requirement detail.

  • EEO Footer: 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.
  • Requisition ID: 21001E3
  • Posting Date: Apr 23, 2021
  • Schedule: Full-time

Keywords: Blue Shield of California, Oakland , Risk Adjustment Consulting, Consultant, Other , Oakland, California

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