Risk Adjustment Consulting, Consultant
Company: Blue Shield of California
Posted on: June 6, 2021
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
- Establish positive, long-term, consultative relationship with
- 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
- 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
- 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
- Requires minimum of a bachelor's degree in Healthcare
Administration, Business Administration, Master's Degree
- Requires healthcare industry experience, with a thorough
understanding of clinical metrics, claims/encounters, and
- 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
- 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
- Technical/analytic skills.
- 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
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
- 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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