Risk Adjustment Consulting, Experienced

Your Role The Enterprise Retrospective Chart Review team oversees end to end retrospective coding operations, ensuring the accuracy, completeness, and compliance of medical record review across all risk adjusted lines of business. The team manages enterprise workflows, vendor performance, coding quality, audit readiness, and cross functional alignment with Clinical, Compliance, and Risk Adjustment partners. Job Description The Enterprise Retrospective Chart Review team oversees end to end retrospective coding operations, ensuring the accuracy, completeness, and compliance of medical record review across all risk adjusted lines of business. The team manages enterprise workflows, vendor performance, coding quality, audit readiness, and cross functional alignment with Clinical, Compliance, and Risk Adjustment partners. Responsibilities Your Work In this role, you will: Analyze under the supervision of the core principles and functionality of decision and descriptive analytics including analyzing historical data, past performance and trends Develop and run programs that apply to analytic decision techniques Contribute to successful programs for the team, engaged in typically one area related to vendor oversight, internal cross functional partnerships, tracking performance and measuring results Continuously learn about plan data including claim, premium, membership, and risk score assignment Conduct data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals Analyze operational performance to identify trends, risks, and improvement opportunities and to forecast retrieval volumes, coding workloads, and capacity needs using both traditional analytics and AI-driven modeling Design AI-enabled workflows that enhance chart ingestion, data validation, and operational reporting for risk adjustment, using AI tools to improve efficiency and consistency Automate data processes by building Python and SQL solutions and applying AI applications to streamline vendor file processing, recurring reporting, and ad hoc analytics Produce operational reporting through dashboards and scorecards that summarize retrieval performance, coding outcomes, and risk adjustment trends, supported by AI-assisted insight generation Manage data quality by ingesting weekly vendor data loads, performing QA checks, validating accuracy, and applying AI tools to support anomaly detection and data review Qualifications Your Knowledge and Experience Requires a college degree or equivalent experience Requires 3 years of prior relevant experience within healthcare, preferably Risk Adjustment Requires practical knowledge of Risk Adjustment obtained through professional experience and advanced education Requires familiarity with AI tools, including prompt engineering and workflow automation Requires experience building dashboards or visual reports that support operational decision making Requires strong communication skills for concise summaries and effective cross functional collaboration Hybrid This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need. About Us About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us! Our Values Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Equal Employment Opportunity External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws. JOB INFO Job Identification : 20261533 Job Category : Actuarial Services Posting Date : 2026-08-14T15:59:30+00:00 Job Schedule : Full time Locations : Oakland, CA, United States CA, United States Pay Range for California : $37.35 to $56.03 Pay Range for Bay Area : $42.11 to $63.16 Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles. Role can be filled by a candidate requiring sponsorship : No #J-18808-Ljbffr Blue Shield of California