Senior Risk Adjustment Solutions Analyst

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

📋 Description

• Evaluate the performance of Medicare Advantage and ACA Risk Adjustment programs to discover opportunities for enhancing RAF and optimizing revenue.

• Offer expertise in CMS-HCC, RxHCC, Medicare Risk Adjustment methods, and industry best practices.

• Assess operational and financial performance metrics and craft data-driven recommendations.

• Assist in client-facing initiatives, business reviews, and executive presentations.

• Analyze, cleanse, transform, reconcile, and validate extensive healthcare datasets from various sources.

• Conduct analyses across Claims, Encounters, Eligibility, Pharmacy, Medical Record Review (MRR), and Health Assessment datasets.

• Detect trends, anomalies, and opportunities through thorough data analysis.

• Perform root cause analysis and suggest corrective measures to enhance data integrity and operational performance.

• Work extensively with CMS data sources, including MMR, MOR, and additional Medicare Advantage datasets.

• Assist in Risk Adjustment reconciliation, forecasting, and financial impact assessments.

• Create operational reports, scorecards, ad hoc analyses, and executive dashboards.

• Convert complex analytical findings into actionable business recommendations.

• Develop, optimize, and troubleshoot intricate SQL queries, stored procedures, and data extraction methods.

• Debug existing reporting and analytical scripts.

• Collaborate with business, operations, technology, and analytics teams to implement scalable solutions.

• Support initiatives for automation, process improvement, and operational excellence.

⛳️ Requirements

• Bachelor's degree in Healthcare, Statistics, Computer Science, Engineering, Business Analytics, or a related discipline.

• Over 5 years of experience in healthcare data analytics, encompassing data mining, mapping, transformation, validation, and reporting.

• At least 3 years of hands-on experience in Medicare Advantage and/or ACA Risk Adjustment.

• Minimum of 3 years working experience as a Healthcare Data Analyst.

• 3+ years of advanced SQL development experience.

• Solid understanding of Medicare Advantage and ACA Risk Adjustment programs.

• Comprehensive knowledge of CMS-HCC and RxHCC models.

• Profound understanding of Medical Record Review (MRR) and Health Assessment processes.

• Strong familiarity with Claims, Encounter, Eligibility, and Pharmacy data.

• In-depth knowledge of CMS data files, including MMR and MOR.

• Thorough understanding of the entire Risk Adjustment lifecycle.

• Strong grasp of HEDIS and healthcare quality measures.

• Proficiency in advanced SQL and Microsoft SQL Server.

• Familiarity with SQL Server Management Studio (SSMS).

• Experience in data mapping, reconciliation, and validation.

• Skills in root cause analysis and data quality management.

• Expertise in ad hoc reporting and data extraction.

• Strong analytical and problem-solving skills.

• Excellent communication and presentation abilities.

• Experience in direct collaboration with clients and executive stakeholders.

• Capability to independently manage multiple priorities in a dynamic environment.

🏝️ Benefits

• Health Care Plan (Medical, Dental & Vision)

• Annual Performance Bonus

• Retirement Plan (401k, IRA)

• Life Insurance (Basic, Voluntary & AD&D)

• Paid Time Off (Vacation, Sick & Public Holidays)

• Family Leave (Maternity, Paternity)

• Short Term & Long Term Disability

• Work From Home

• Wellness Resources