Senior Risk Adjustment Analyst

Senior Risk Adjustment Analyst

Senior Risk Adjustment (RA) Analyst assists in accurate and comprehensive data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable populations.

Leverages available tools and knowledge of applicable risk models to optimise data submission for Hierarchical Condition Categories (HCCs), HEDIS and quality performance as well as other data within a given system.

Collaborates and coordinates with internal and external partners to minimise submission and response errors, provides oversight of vendor partners, accumulates and reports on pertinent data sets, develops and improves processes related to risk adjustment and quality improvement, maintains required documentation, and ensures compliance with all applicable laws, guidance, and regulations.

• Recommend and guide process improvements that optimise risk adjustment factor increases while minimising inaccurate capture of disease burden.
• Identify, analyse, interpret and communicate risk adjustment trends to provider partners and related entities.
• Maintain existing reports, develop new reports to ensure company goals are met and complete ad‑hoc requests as needed.
• Develop and maintain reporting capabilities to measure and forecast risk scores and quality metrics, monitor suspicious model performance and identify areas of improvement.
• Maximise risk adjustment revenue and quality bonus payments by driving data integration and analytics to properly capture and improve the health status of Pacific Source members.
• Validate data integrity and collaborate with technical teams to improve data pipelines and business logic for identified areas of opportunity.
• Identify and lead internal subject‑matter experts in regular meetings to identify and rectify data submission and adjudication errors related to risk adjustment and quality data submission.
• Develop and maintain data sets leveraging internal data, response data from regulatory entities (including but not limited to EDGE files, MMR, MOR, RAPS response, MAO‑004, PSV, PLD, etc.) and ancillary sources for enterprise use.
• Demonstrate mastery in running applicable risk models, including CMS models for Medicare Advantage members, the HHS model for Commercial ACA members, and others as needed.
• Maintain strict oversight of vendor partners through analytic reconciliations to ensure regulatory compliance, optimal data submission and error resolution, and general accuracy.
• Assist with all pertinent audits, including RADV, through preparation activities and documentation.
• Perform root‑cause analysis to maintain high data integrity and processes to minimise discrepancies and gaps.
• Maintain familiarity with current CMS regulations and announcements affecting risk adjustment and CMS Star Ratings; review regulatory announcements, attend educational sessions and pursue industry opportunities.
• Develop, maintain and report actionable metrics related to risk adjustment and HEDIS to incorporate quality/health outcome metrics where applicable.
• Prepare new and review existing specifications, project plans and other internal procedural documents.
• Ensure users and partners understand the nature of work, time frames and milestones.
• Provide regular status updates to supervisors and stakeholders.
• Provide support for projecting annual receivable amounts, preparing pricing projections and predicting cost utilisation as it relates to risk adjustment.
• Coordinate releases and modifications of changing data file specifications through approved procedures.
• Collaborate with internal and external partners to resolve data issues related to member, claim, provider and pharmacy data and processes.
• Support risk adjustment activities across internal teams, provider partners and vendor partners as needed.
• Provide mentorship, leadership and training to less experienced risk adjustment analysts.

• Meet department and company performance and attendance expectations.
• Follow Pacific Source privacy policy and HIPAA laws concerning confidentiality and security of protected health information.
• Participate in and support project teams led…