Risk Adjustment Data Architect, CMS Edge Server

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

📋 Description

• Act as the CMS EDGE Server / Risk Adjustment Data Architect and a subject matter expert for ACA risk adjustment, reinsurance, and CMS regulatory reporting initiatives.

• Design and manage the comprehensive architecture of the CMS EDGE Server, including the integration of source systems, data ingestion, transformation, validation, reconciliation, submission readiness, and error resolution.

• Lead the implementation, upgrades, enhancements, production support, and operational stabilization of the CMS EDGE Server for payer clients.

• Convert CMS/HHS reporting requirements, business rules, and regulatory updates into technical designs, solution roadmaps, data specifications, and implementation plans.

• Collaborate with payer business, actuarial, risk adjustment, compliance, data engineering, IT, and vendor teams.

• Establish and enhance data quality controls across membership, eligibility, claims, encounter, provider, and supplemental diagnosis data.

• Conduct root-cause analysis on submission errors, data defects, reconciliation gaps, and downstream reporting issues; guide remediation strategies.

• Create architecture documentation, data flow diagrams, business and technical requirements, user stories, acceptance criteria, and operational playbooks.

• Offer client-facing advisory support on CMS EDGE Server best practices, implementation risks, reporting timelines, data governance, and production readiness.

⛳️ Requirements

• Over 7 years of experience in healthcare payer roles with significant exposure to ACA, risk adjustment, reinsurance, regulatory reporting, and payer data operations.

• Extensive hands-on experience with CMS EDGE Server architecture, implementation, operations, configuration, data submission workflows, and production support.

• Comprehensive understanding of CMS/HHS requirements, ACA EDGE Server reporting, risk adjustment transfer payment processes, reinsurance reporting, and regulatory submission timelines.

• Experience in designing or supporting data pipelines and interfaces across payer source systems, claims platforms, encounter processing, membership/eligibility systems, and CMS-facing reporting environments.

• Proven capability to define technical architecture, data mapping, validation rules, reconciliation logic, exception reporting, and operational controls for CMS EDGE Server submissions.

• Experience collaborating directly with health plan stakeholders, technology teams, vendors, and compliance partners in client-facing advisory or consulting roles.

• Strong skills in documentation, communication, facilitation, and managing executive stakeholders, with the ability to articulate technical issues to business and compliance audiences.

• Preferred: Familiarity with Cognizant CMS EDGE Server, ClaimSphere, Facets (TriZetto), HealthRules, QNXT, or other payer core administration and reporting platforms.

• Preferred: Experience with SQL, data analysis, data profiling, ETL/ELT concepts, data lineage, exception reporting, and healthcare data quality management.

• Preferred: Knowledge of Medicare Advantage, Medicaid, commercial exchange, HEDIS, CMS STARs, encounter data, risk adjustment analytics, or quality reporting programs.

• Preferred: Experience in developing product roadmaps, solution designs, implementation plans, user stories, test plans, operational readiness materials, and governance reporting.

• Preferred: Familiarity with Agile delivery, Jira, Azure DevOps, Confluence, Power BI, Visio, Lucidchart, or similar tools.

• Must be a U.S. Citizen.

• H-1B, C2C, and 1099 candidates are not considered.

🏝️ Benefits

• Medical, dental, and vision coverage for employees and their dependents.

• 401(k) plan featuring a generous employer match.

• Employee stock purchase plan.

• Generous Paid Time Off policy.

• Paid parental leave.

• Adoption assistance.

• Wellness Program offering free annual health screenings and coaching.

• Bank at work.

• On-site workshops.

• Ongoing programs recognizing significant employee life events.