Job Description

Job Title: Senior Risk Adjustment Analyst
Job Location: California


  • Perform analysis and reporting activities relating to: risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics
  • Analysis and reporting on RAF Forecast Model and risk adjusted revenue PMPM by plan/patient cohorts and review cost and utilization trends to understand impact on revenue; along with reconciliation and root cause analysis for any variance
  • Analysis and reporting of revenue results to assist financial reporting, forecasting, and budget development
  • Design and develop dashboard for reporting related to Risk Adjustment and Senior Revenue Finance
  • Analysis and reporting on HCC program initiatives relative to benchmarks/targets
  • Analysis and reporting on CMS data like MMR and MOR received through various health plans
  • Develop tools and conduct analysis to evaluate accuracy and completeness of encounter exchange with capitated providers
  • Work with EDI team to ensure timely and accurate encounter submissions to health plans and other state or federal agencies
  • Analyze the financial impact of data issues and encounter rejection buckets
  • Communicate and collaborate with internal and external stakeholders on risk adjustment related analysis, knowledge, or both
  • Comply with HIPAA Regulations and company compliance policy
  • Stay updated and share knowledge on industry changes especially any changes on CMS side (changes like ICD10, EDS, Payment Model Changes)

Required Qualifications:

  • Bachelor’s degree from a four-year college required
  • Five to seven years of healthcare analytics experience
  • Strong understanding of Medicare Risk Adjustment Payment Model and Cycle including the knowledge base to calculate and manipulate risk scores
  • Deep familiarity with CMS data and risk adjustment processes including MMR, MOR and EDS data
  • Strong understanding of Claims and Encounter data
  • Strong command on SQL Server (T-SQL), SSIS and SSRS, and Database design
  • Strong analytical/financial skills
  • Proficient with Microsoft Office, Access, and Visio

Preferred Qualifications:

  • Major in information systems or related quantitative field (finance, computer science or, mathematics)
  • Experience with Risk Score and Revenue forecast

QBH#: 2069

Application Instructions

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