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
Street: ArchCare Community Services
Shift Start Time: 9:00am
Shift End Time: 5:00pm
External Company URL: http://www.archcare.org/