Principal Risk Adjustment, Revenue Integrity Analytics Lead

🕒 September 29

🇺🇸 United States – Remote

💵 $133.2k - $180.9k / year

⏰ Full Time

🟠 Senior

📊 Data Scientist

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Lumeris

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

☁️ SaaS

Healthcare • Healthcare Insurance • SaaS

Lumeris is a company focused on providing value-based care solutions within the healthcare industry. With over a decade of leadership in this field, Lumeris partners with health systems to improve patient outcomes and drive financial success through tech-enabled solutions. Their platform supports population health management, clinical delivery transformation, and payer contracting, offering comprehensive solutions for acute, post-acute, and high-risk patient management. Lumeris is recognized for creating significant cost savings and achieving excellent patient outcomes, including a 5-star CMS rating for its Medicare Advantage Prescription Drug Plan.

📋 Description

• Design, build, and maintain primary analytic assets, dashboards, and reporting for Part C and Part D risk-score performance • Develop and maintain risk-score and revenue forecasting models, compare projections to actuals, and decompose variances into documented drivers • Trace diagnoses and HCCs from source to payment using submission and response data such as EDPS and MAO-004 • Create repeatable reconciliation controls across the diagnosis-to-payment lifecycle • Analyze and track recapture and chart-review recovery opportunities using documented valuation rules • Partner with internal teams to prioritize opportunities and measure performance by provider, program, vendor, and intervention • Automate recurring reporting through scalable dashboards, reusable SQL, documented business logic, and repeatable processes • Own business logic, metric definitions, and data-quality criteria for accurate, reproducible reporting • Translate complex model, coding, and financial logic into decision-ready narratives for leadership and non-technical stakeholders • Monitor Medicare Advantage Risk Adjustment regulatory changes and quantify their impact on data, forecasts, and operations • Serve as analytic truth owner and senior builder/strategic partner to Risk Adjustment, Finance, Actuarial, and other departments • Report directly to the Senior Director of Health Plan Analytics and partner with the VP of Risk Adjustment Solutions and Strategy

🎯 Requirements

• 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 • 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 • Advanced degree in Analytics, Economics, Health Informatics, Finance, Actuarial Science, Business Administration, or a related field preferred • Experience with Part D risk-score analytics, PDE, coding/chart-review programs, provider risk arrangements, or using Python/R for advanced analytics preferred • Authorized to work in the United States; visa sponsorship is unavailable

🏖️ Benefits

• 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 • Performance-based incentive and/or equity may be available depending on the position • Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties