JOB SUMMARY:The Senior Risk Adjustment Analyst leads advanced analytics, data governance, and operational processes that support accurate, compliant, and optimized risk-adjusted revenue across Medicare Advantage and ACA populations. This role requires independent execution, strong technical skills, and the ability to translate complex healthcare data into actionable insights for internal and external stakeholders.
KEY RESPONSIBILITIES:- Co-design and lead risk adjustment analytics for MA and ACA populations, including KPI development and RAF trending.
- Analyze large datasets integrating claims, encounters, pharmacy, eligibility, EDPS/EDGE, and provider data to identify trends, patterns, and anomalies; synthesize findings into clear recommendations.
- Develop, modify, and optimize SAS or SQL, and Power BI to support data extraction, transformation, validation, and analytics.
- Oversee end-to-end EDPS and EDGE submission processes, including data gathering, ETL workflows, file transfers, and vendor/government response file management.
- Investigate and resolve submission errors, outliers, and rejections; implement process improvements and automation opportunities.
- Build paginated reports and interactive dashboards in Power BI, including reusable templates and automated refresh pipelines.
- Create written reports and presentations that communicate analytical findings to leadership and operational teams.
- Partner with internal teams (coding, finance, compliance, provider engagement, pharmacy, IT) to gather requirements and deliver analytical solutions.
- Support external partners including providers, delegated entities, and vendors by clarifying data needs and resolving issues.
- Performs other job-related duties as assigned.
QUALIFICATIONS:- Strong understanding of MA and ACA risk-adjustment models, EDPS/RAPS/EDGE processes, and healthcare data structures.
- Advanced proficiency in SAS or SQL, and Power BI.
- Strong analytical, problem solving, and data interpretation skills.
- Strong written and verbal communication skills, including the ability to present findings clearly to technical and non-technical audiences.
- Demonstrated ability to collaborate with analysts and cross functional teams.
- Consistent professionalism in interactions with internal and external partners.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:- Bachelor's degree in analytics, statistics, health informatics, business, or related field, with a minimum of three (3) years of healthcare analytics, risk adjustment, or population health experience.
- Experience building dashboards, ETL processes, and analytic data models.
