Archcare Risk Adjustment Reconciliation Specialist in New York, New York

The Risk Adjustment Reconciliation Specialist is responsible for reviewing Medicare/Medicaid submissions and response reports for reconciliation of Encounter/Risk Adjustment data. The Specialist will conduct analytical studies and audits against internal claim processing system to ensure reconciliation Risk Adjustment/ Encounter data submitted to CMS and NYS. The Specialist is responsible for 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. The position is heavily involved with research, investigation and correction of encounter submission data. Must develop and maintain detailed documentation that provides traceability for all regulatory data. Will document and present all findings to the Risk Adjustment Manager via report summaries. Will also be responsible for timely completion of special projects, including timeline development & maintenance as it pertains to Encounter Risk Adjustment Data submission. Administrator and Maintenance of Ability MD Online demographics for Facility, Provider and Member Eligibility data for encounter data entry. Also, will also 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.

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

ID: 2018-12272

Street: ArchCare Community Services

Shift Start Time: 9:00am

Shift End Time: 5:00pm

Hours: 35

External Company URL: