Note: The job is a remote job and is open to candidates in USA. Healthcare IS is expanding its healthcare quality and risk adjustment initiatives and is seeking a senior-level resource focused specifically on CMS EDGE Server and Risk Adjustment operations. The role involves evaluating existing capabilities and enhancing processes to improve performance and scalability.
Responsibilities
- Evaluate existing CMS EDGE capabilities
- Enhance current processes
- Help design a future-state strategy for improved performance and scalability
Skills
- Demonstrated expertise with CMS EDGE Server processes, including EDGE data extraction, eligibility and claims processing, data validation and cleansing, submission workflows, CMS reporting requirements, Medicare and Exchange market submissions
- Strong understanding of Medicare Advantage programs, risk adjustment methodologies, HCC coding concepts, RAF score optimization, STAR measures, CMS reimbursement implications, quality and performance initiatives
- Experience within health plans, managed care organizations, Medicare Advantage environments, government-sponsored healthcare programs
- Understanding of the end-to-end lifecycle associated with claims, eligibility data, extraction, formatting, and submission to CMS
- TriZetto CMS EDGE components
- Facets
- QNXT data extraction and transformation processes
- Healthcare data governance
- Data quality management
- Submission optimization initiatives
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