Position:Principal Risk Adjustment & Revenue Integrity Analytics Lead
Position Summary:The Principal Risk Adjustment & Revenue Integrity Analytics Lead is a senior, hands-on analytics leader responsible for designing, building, validating, and operationalizing Medicare Advantage Part C risk adjustment analytics. Reporting directly to the Senior Director of Health Plan Analytics, this role directly supports the Medicare Advantage plans of Essence Healthcare, serving as the analytic truth owner for Risk Adjustment by connecting risk-score performance, diagnosis and HCC capture, encounter submissions, and revenue impact into a single, trusted operating model. The lead will partner closely with the VP of Risk Adjustment Solutions and Strategy to align technical analytic models with overall business operations and strategic interventions.
The lead is expected to work independently, translating complex data from claims, encounters, eligibility, and CMS sources into actionable performance intelligence. This individual will act as a senior builder and strategic partner to Risk Adjustment, Finance, Actuarial, and other key departments. The ideal candidate will be a domain owner who can distinguish the drivers of financial performance-whether it's population mix, model changes, or operational execution-and establish an auditable fact base for action. This role is pivotal in shifting the function from retrospective reporting to proactive risk and revenue intelligence.
Job Description:Primary Responsibilities- Build and Own Risk Adjustment Analytic Truth: Design, build, and maintain the primary analytic assets, dashboards, and reporting for Part C and Part D risk-score performance.
- Forecast Part C RAF, Bid/Budget Performance, and Revenue: Develop and maintain risk-score and revenue forecasting models, comparing projections to actuals and decomposing any variances into documented drivers.
- Reconcile the Diagnosis-to-Payment Lifecycle: Trace diagnoses and HCCs from source to payment, analyzing submission and response data (e.g., EDPS, MAO-004) to create repeatable reconciliation controls.
- Identify, Size, and Track Recovery Opportunities: Analyze and track opportunities such as recapture and chart reviews using documented valuation rules, ensuring clear ROI visibility and preventing double counting.
- Drive Risk Adjustment Provider, Vendor, and Operational Performance: Partner with internal teams to prioritize high-impact opportunities and measure performance by provider, program, vendor, and intervention.
- Automate and Scale Risk Adjustment Intelligence: Automate recurring reporting to reduce manual effort through scalable dashboards, reusable SQL, documented business logic, and repeatable processes.
- Own Risk Adjustment Business Logic and Data Trustworthiness: Own the domain's business logic, metric definitions, and data quality criteria to ensure all reporting is accurate, reproducible, and fit for executive use.
- Communicate Executive-Ready Performance Narratives: Translate complex model, coding, and financial logic into clear, decision-ready narratives for leadership and non-technical stakeholders.
- Monitor CMS Regulation & Quantify Impact: Serve as a senior subject matter expert on Medicare Advantage Risk Adjustment, monitoring regulatory changes and quantifying their impact on the organization's data, forecasts, and operations.
Qualifications- Bachelor's degree in a related field such as Mathematics, Statistics, Computer Science, Data Analytics, Health Informatics, Finance, or Actuarial Science.
- 8+ years of healthcare analytics experience, with direct experience in Medicare Advantage Part C Risk Adjustment, RAF, CMS-HCC, and risk-adjusted payment performance.
- Demonstrated experience analyzing Part C risk-score performance, including model impacts, coding trends, population mix, and submission outcomes.
- Experience with Risk Adjustment data flows, including claims/encounters, eligibility, provider data, supplemental files, EDPS, MAO-004, and MMR/payment data.
- Ability to build and reconcile forecast-to-actual performance across Bid, Budget, projections, and final reconciliation.
- Hands-on experience writing complex SQL to extract and reconcile data from large-scale data environments.
- Experience building dashboards and automated reports using tools like Power BI or Tableau.
- Experience designing validation, QA, and reconciliation controls for high-stakes financial or healthcare analytics.
- Experience using AI-enabled analytics, automation, or advanced statistical tools to accelerate insight generation.
- Ability to self-direct analyses, manage ambiguity, and deliver actionable insights with limited direction.
- Strong communication skills with the ability to explain complex drivers to senior leadership.
Preferred- Advanced degree in Analytics, Economics, Health Informatics, Finance, Actuarial Science, Business Administration, or a related field.
- Experience with Part D risk-score analytics, PDE, coding/chart-review programs, provider risk arrangements, or using Python/R for advanced analytics.
Working Conditions- While performing the duties of this job, the employee works in normal office working conditions.
#LI-REMOTE
Pay Transparency:Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.
The hiring range for this position is:
$133,200.00-$180,900.00
Benefits of working at Lumeris
- 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
- And much more...
Be part of a team that is changing healthcare!
Member Facing Position: No- Not Member or Patient Facing Position
Drug Screen Requirement: No
MVR Required:No
Credit Check Required:No
Location:Remote, USA
Time Type:Full time
