Risk Adjustment - Risk Adjustment Data Analyst II 135-2008

JOB SUMMARY:

The Risk Adjustment Analyst II supports the organization’s Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs by managing data submissions, developing reporting, and delivering actionable analytics. This role is responsible for ensuring the accuracy and integrity of encounter and risk score data, including RAF (MA) and PLRS (ACA) reporting.

KEY RESPONSIBILITIES:

Manage Centers for Medicare & Medicaid Services (CMS) encounter submissions and ACA data processes including EDGE/PLRS reporting. Perform data validation, reconciliation, and root cause analysis to identify and resolve variances between submitted data and CMS-accepted data. Analyze submission errors, response files, and rejection trends to improve data quality and acceptance rates. Develop and maintain risk score reporting, key performance indicators (KPIs) and dashboards such as risk adjustment factor (RAF), plan liability risk score (PLRS), enrollment, drivers, population trends. Prepare monthly production and performance reports across retrieval, coding, and vendor operations. Support retrospective chart reviews and risk adjustment data validation (RADV) activities, including chase list development. Write complex SQL queries and integrate data across claims, encounters, enrollment, pharmacy, and vendor sources. Partner with vendors and internal teams to improve data quality, reporting, and operational performance. Analyze CMS response files such as MAO-004 and monthly membership reports (MMR); ensure conditions are being captured, reported accurately and accepted by CMS’s data systems; identify trends in risk scores, enrollment, population segments and identify new initiative opportunities. Mentor and support junior analysts to promote consistency and best practices across the team. Translate data into actionable business insights and proactively recommend process improvements. Serve as a subject matter resource for risk adjustment data, submissions, and reporting. Perform other job-related duties as required or assigned.

QUALIFICATIONS:

Ability to apply advanced mathematical and statistical techniques to the analysis of healthcare and risk adjustment data (MA and ACA). Demonstrated ability to independently manage work, prioritize competing demands, and drive projects to completion with minimal supervision. Strong oral and written communication skills, with the ability to clearly present risk adjustment data, reporting insights, and findings to diverse audiences. Demonstrated knowledge of programming, including writing, modifying, and optimizing queries (SQL preferred). Demonstrated knowledge of healthcare data, including claims, encounters, enrollment, and provider data, with a strong understanding of risk adjustment processes and data flows. Working knowledge of Medicare Advantage and/or ACA risk adjustment methodologies, including HCC models, encounter submissions, and/or EDGE/PLRS reporting processes. Experience analyzing CMS and/or ACA response files, submission errors, and reconciliation outputs preferred. Proficient in the use of Microsoft Office applications, including Excel preferred. Strong analytical, critical thinking, and problem-solving skills, with the ability to perform root cause analysis and data validation. Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

Bachelor’s degree required. Degree in Mathematics, Statistics, Economics, Actuarial Science or other quantitative discipline preferred. Master’s degree is a plus. Demonstrated use of analytical tools such as SAS or SQL. Experience with Power BI, Tableau, or other similar visualization tools preferred. A minimum of three years of Health Data analysis experience required. Two or more years of risk adjustment experience preferred. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin