Principal Risk Adjustment, Revenue Integrity Analytics Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Design, develop, and sustain primary analytic assets, dashboards, and reporting for Part C and Part D risk-score performance.

• Create and maintain risk-score and revenue forecasting models, compare forecasts to actuals, and analyze variances into clearly documented drivers.

• Track diagnoses and Hierarchical Condition Categories (HCCs) from source to payment utilizing submission and response data such as EDPS and MAO-004.

• Establish repeatable reconciliation controls throughout the diagnosis-to-payment lifecycle.

• Examine and monitor recapture and chart-review recovery opportunities based on documented valuation rules.

• Collaborate with internal teams to prioritize opportunities and evaluate performance by provider, program, vendor, and intervention.

• Automate recurring reporting through scalable dashboards, reusable SQL, documented business logic, and consistent processes.

• Own the business logic, metric definitions, and data-quality standards for precise, reproducible reporting.

• Transform complex models, coding, and financial logic into decision-ready narratives for leadership and non-technical stakeholders.

• Keep track of Medicare Advantage Risk Adjustment regulatory changes and assess their effects on data, forecasts, and operations.

• Act as the analytic truth owner and senior builder/strategic partner to Risk Adjustment, Finance, Actuarial, and other departments.

• Report directly to the Senior Director of Health Plan Analytics and collaborate with the VP of Risk Adjustment Solutions and Strategy.

⛳️ Requirements

• Bachelor's degree in a relevant field such as Mathematics, Statistics, Computer Science, Data Analytics, Health Informatics, Finance, or Actuarial Science.

• Over 8 years of healthcare analytics experience, specifically in Medicare Advantage Part C Risk Adjustment, RAF, CMS-HCC, and risk-adjusted payment performance.

• Proven experience in analyzing Part C risk-score performance, including model impacts, coding trends, population mix, and submission outcomes.

• Familiarity with Risk Adjustment data flows, such as claims/encounters, eligibility, provider data, supplemental files, EDPS, MAO-004, and MMR/payment data.

• Capability to construct and reconcile forecast-to-actual performance across Bid, Budget, projections, and final reconciliation.

• Practical experience writing complex SQL to extract and reconcile data from extensive data environments.

• Expertise in developing dashboards and automated reports using tools like Power BI or Tableau.

• Experience in designing validation, QA, and reconciliation controls for critical financial or healthcare analytics.

• Proficient in utilizing AI-enabled analytics, automation, or advanced statistical tools to expedite insight generation.

• Ability to independently direct analyses, manage uncertainty, and provide actionable insights with minimal guidance.

• Exceptional communication skills with the capacity to articulate complex drivers to senior leadership.

• Advanced degree in Analytics, Economics, Health Informatics, Finance, Actuarial Science, Business Administration, or a related field is preferred.

• Experience with Part D risk-score analytics, PDE, coding/chart-review programs, provider risk arrangements, or utilizing Python/R for advanced analytics is preferred.

• Authorized to work in the United States; visa sponsorship is not available.

🏝️ Benefits

• Medical, Vision, and Dental Plans.

• Tax-Advantage Savings Accounts (FSA & HSA).

• Life Insurance and Disability Insurance.

• Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days).

• Employee Assistance Program.

• 401k with company match.

• Employee Resource Groups.

• Employee Discount Program.

• Learning and Development Opportunities.

• Performance-based incentive and/or equity may be available depending on the position.

• Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties.