Quality & Risk Adjustment Specialist at Abarca Health

Sioux Falls, South Dakota, United States

Apply Now

$42,640 – $56,160Compensation

Entry Level & New Grad, Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

4-6 years professional experience in insurance or managed care industry
Visual acuity adequate to perform position duties
Ability to communicate effectively with others, hear, understand, and distinguish speech and other sounds
Bachelor's degree or combination of education and experience (preferred)
Commitment to Avera’s mission, vision, core values, and social principles
Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE)
Maintain confidentiality
Work effectively in a team environment
Comply with safety principles, laws, regulations, and standards (e.g., CMS, The Joint Commission, DHHS, OSHA)

Responsibilities

Understand the rationale behind Risk Adjustment (RA)
Work with physicians, clinic staff, coding, and other Health Plans staff to resolve coding or work process issues related to RA
Support clinic RA visits & audits
Ensure appropriate parties complete designated RA tasks
General understanding of Hierarchical Condition Coding
Oversight of External Data Gathering Environment (EDGE) submission process
Observe, investigate, and report trending issues which may cause quality or RA gaps
Expand job-related knowledge through participation in approved continuing education, in-services, offsite meetings, and webinars related to Risk Adjustment and HEDIS
Support annual RADV (Risk Adjustment Data Validation) audit with multiple Health Plans departments
Participate in HEDIS abstraction efforts in collaboration with Quality Coordinator – HEDIS
Support member and provider outreach initiatives to close quality and RA gaps
Identify opportunities for synergies related to medical record review and manage the medical record request process for Quality and RA
Ensure medical records for identified members are retrieved, reviewed, and documented appropriately for all Quality and RA initiatives

Skills

Key technologies and capabilities for this role

Risk AdjustmentHEDISHierarchical Condition CodingMedical Records ReviewClinical DocumentationCodingRA AuditsEDGE SubmissionRADV AuditHEDIS Abstraction

Questions & Answers

Common questions about this position

What is the pay range for the Quality & Risk Adjustment Specialist position?

The pay range is $20.50 - $27.00, with actual pay rate dependent upon experience.

Is this a remote position, or does it require on-site work?

This information is not specified in the job description.

What are the key responsibilities or skills needed for this role?

Key responsibilities include understanding Risk Adjustment rationale, working with physicians and staff to resolve coding issues, supporting clinic RA visits and audits, overseeing EDGE submissions, and participating in HEDIS abstraction and RADV audits.

What is the work schedule for this position?

The schedule is Monday-Friday 8:00am-5:00pm, 80 hours every 2 weeks, with no weekends.

What kind of team will I be working with in this role?

You will be part of a multidisciplinary team built with compassion, working closely with the Director of Quality and Risk Services, Manager of Risk Adjustment, Manager of Quality, Quality Coordinator – HEDIS, coders, claims staff, and primary care & specialty care providers.

Abarca Health

Pharmacy Benefit Management services provider

About Abarca Health

Abarca Health provides Pharmacy Benefit Management (PBM) services, focusing on flexible and user-friendly solutions for health plans, employers, and government programs like Medicare and Medicaid. Its main product, the Darwin platform, allows clients to quickly implement and modify benefit designs while ensuring compliance with regulations. Abarca Health manages over $5.3 billion in drug spend and processes 100 million prescription claims annually, offering additional services like home delivery for prescriptions. The company's goal is to deliver exceptional service and innovative solutions in the PBM market.

Aventura, FloridaHeadquarters

2005Year Founded

VENTURE_UNKNOWNCompany Stage

HealthcareIndustries

501-1,000Employees

Benefits

PTO

Parental leave

Work flexibility

Health insurance

Wellness stipend

401k

Tuition reimbursement

Leadership development programs

Risks

Increased competition from Amazon Pharmacy and Mark Cuban's Cost Plus Drug Company.

Growing focus on specialty drugs may require platform adaptation.

Shift towards price transparency could pressure Abarca's pricing models.

Differentiation

Abarca Health's Darwin platform is highly adaptable and user-friendly.

The company offers innovative programs like Triple S en Casa for home delivery.

Abarca Health ensures compliance with ever-changing healthcare regulations.

Upsides

Abarca transitioned two million members to Darwin in 18 months, showing operational efficiency.

Collaboration with Blue Shield of California boosts Abarca's reputation in the PBM sector.

Recognition as a top IT workplace attracts top talent, driving innovation.

Land your dream remote job 3x faster with AI

Try Jobo Free