Senior Risk Adjustment Solutions Analyst

🕒 October 8

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

🧐 Business Analyst

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Advantmed

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

💼 Consulting

🛡️ Insurance

📦 Logistics

💰 Venture Round on 2016-12

Consulting • Insurance • Logistics

Advantmed is a company that specializes in providing integrated solutions to healthcare organizations, aiming to enhance the performance of health plans and providers. The company focuses on key areas such as risk adjustment, quality improvement, and health assessments, using its Elevate^ platform to deliver real-time data visibility and insights. With a commitment to market-leading accuracy, flexibility, and transparency, Advantmed partners with healthcare clients to improve outcomes, financial performance, and data accuracy. Their comprehensive services cater to both health plans and providers, enhancing member engagement, identifying care gaps, and ensuring accurate reimbursement and care delivery.

📋 Description

• Analyze Medicare Advantage and ACA Risk Adjustment program performance to identify opportunities for RAF improvement and revenue optimization • Provide expertise on CMS-HCC, RxHCC, Medicare Risk Adjustment methodologies, and industry best practices • Evaluate operational and financial performance metrics and develop data-driven recommendations • Support client-facing initiatives, business reviews, and executive presentations • Analyze, cleanse, transform, reconcile, and validate large healthcare datasets from multiple sources • Perform analysis across Claims, Encounters, Eligibility, Pharmacy, Medical Record Review (MRR), and Health Assessment datasets • Identify trends, anomalies, and opportunities through detailed data analysis • Conduct root cause analysis and recommend corrective actions to improve data integrity and operational performance • Work extensively with CMS data sources, including MMR, MOR, and other Medicare Advantage datasets • Support Risk Adjustment reconciliation, forecasting, and financial impact analysis • Develop operational reports, scorecards, ad hoc analyses, and executive dashboards • Translate complex analytical findings into meaningful business recommendations • Develop, optimize, and troubleshoot complex SQL queries, stored procedures, and data extraction processes • Debug existing reporting and analytical scripts • Collaborate with business, operations, technology, and analytics teams to implement scalable solutions • Support automation, process improvement, and operational excellence initiatives

🎯 Requirements

• Bachelor's degree in Healthcare, Statistics, Computer Science, Engineering, Business Analytics, or related field • 5+ years of healthcare data analytics experience, including data mining, mapping, transformation, validation, and reporting • 3+ years of hands-on experience in Medicare Advantage and/or ACA Risk Adjustment • 3+ years of experience as a Healthcare Data Analyst • 3+ years of advanced SQL development experience • Strong understanding of Medicare Advantage and ACA Risk Adjustment programs • Strong understanding of CMS-HCC and RxHCC models • Strong understanding of Medical Record Review (MRR) and Health Assessment processes • Strong understanding of Claims, Encounter, Eligibility, and Pharmacy data • Strong understanding of CMS data files, including MMR and MOR • Strong understanding of the end-to-end Risk Adjustment lifecycle • Strong understanding of HEDIS and healthcare quality measures • Advanced SQL and Microsoft SQL Server • SQL Server Management Studio (SSMS) • Data mapping, reconciliation, and validation • Root cause analysis and data quality management • Ad hoc reporting and data extraction • Strong analytical and problem-solving abilities • Excellent communication and presentation skills • Experience working directly with clients and executive stakeholders • Ability to independently manage multiple priorities in a fast-paced 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

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