Clinical Risk Management Analyst

Blue Cross and Blue Shield of North Carolina

1d•Hybrid

About The Position

The Clinical Risk Management Analyst serves in a provider facing, consultative role focused on advancing accurate, compliant risk adjustment documentation and coding performance across multiple lines of business. This role applies advanced risk adjustment analytics, clinical expertise, and regulatory knowledge to translate complex data into clear, actionable insights for providers, practices, and internal stakeholders. Working closely with Risk Analytics, Quality, Cost of Care, Coding Audit, Member Engagement, and Chart Outreach teams, the analyst supports CMS compliant HCC capture, audit readiness, and sustained provider performance improvement through targeted education, workflow optimization, and data driven engagement strategies. Provider Engagement & Education Deliver provider‑ and practice‑level education on risk adjustment documentation and ICD‑10‑CM coding best practices using performance data, audit findings, and CMS guidance Translate complex risk adjustment analytics into clear, actionable insights for clinical and non‑clinical audiences Provide timely, objective feedback to providers and practice leadership, including recommended action plans when performance gaps or risks are identified Participate in provider and cross‑functional meetings to drive documentation improvement, workflow optimization, and sustained performance gains Risk Adjustment Analytics & Reporting Develop and maintain benchmarking, trending, and month‑over‑month performance reporting at the provider, practice, and departmental level Design, automate, and sustain repeatable risk adjustment reporting workflows, including gap identification, closed‑gap logic, and performance summaries Apply clinical knowledge and analytical judgment to interpret care patterns, performance variation, and regulatory requirements Identify high‑opportunity providers and practices through data‑driven segmentation and trend analysis across MA, ACA, and DSNP populations Compliance, Governance & Audit Readiness Serve as a subject matter expert in risk adjustment coding and documentation, ensuring CMS‑compliant and audit‑defensible practices Maintain up‑to‑date knowledge of CMS rules, risk adjustment policies, and industry trends, translating regulatory requirements into operational guidance Act as the departmental Web Content Management System (WCMS) representative, supporting development and governance of SOPs, analytic methodologies, provider‑facing guidance, and internal workflows Partner with leadership to support audit readiness, quality improvement initiatives, and enterprise change management efforts Cross-Functional Collaboration Collaborate closely with internal partners including Risk Analytics, Quality, Cost of Care Consultants, Member Engagement, Coding Audit, and Chart Outreach Coordinate provider targeting and outreach strategies, resolve documentation and coding barriers, and align improvement efforts with enterprise risk adjustment and quality goals Provide leadership with concise summaries and recommendations on provider performance trends, engagement effectiveness, and improvement opportunities

Requirements

Registered Nurse (RN) with 3+ years of clinical experience OR Licensed Practical Nurse (LPN) with 5+ years of clinical experience
Must have previous work experience in applicable business area (i.e. risk adjustment, provider education, consultation, engagement roles)
CPC or CRC certification required, with demonstrated experience applying ICD‑10‑CM and HCC coding in a risk adjustment environment
CCS (Certified Coding Specialist – AHIMA) will be considered with applicable outpatient ICD‑10‑CM and HCC coding experience

Nice To Haves

Bachelor's degree or advanced degree preferred
Demonstrated ability to communicate analytic findings clearly, deliver provider training, and influence clinical workflow change
Strong analytic, critical‑thinking, and stakeholder collaboration skills

Responsibilities

Deliver provider‑ and practice‑level education on risk adjustment documentation and ICD‑10‑CM coding best practices using performance data, audit findings, and CMS guidance
Translate complex risk adjustment analytics into clear, actionable insights for clinical and non‑clinical audiences
Provide timely, objective feedback to providers and practice leadership, including recommended action plans when performance gaps or risks are identified
Participate in provider and cross‑functional meetings to drive documentation improvement, workflow optimization, and sustained performance gains
Develop and maintain benchmarking, trending, and month‑over‑month performance reporting at the provider, practice, and departmental level
Design, automate, and sustain repeatable risk adjustment reporting workflows, including gap identification, closed‑gap logic, and performance summaries
Apply clinical knowledge and analytical judgment to interpret care patterns, performance variation, and regulatory requirements
Identify high‑opportunity providers and practices through data‑driven segmentation and trend analysis across MA, ACA, and DSNP populations
Serve as a subject matter expert in risk adjustment coding and documentation, ensuring CMS‑compliant and audit‑defensible practices
Maintain up‑to‑date knowledge of CMS rules, risk adjustment policies, and industry trends, translating regulatory requirements into operational guidance
Act as the departmental Web Content Management System (WCMS) representative, supporting development and governance of SOPs, analytic methodologies, provider‑facing guidance, and internal workflows
Partner with leadership to support audit readiness, quality improvement initiatives, and enterprise change management efforts
Collaborate closely with internal partners including Risk Analytics, Quality, Cost of Care Consultants, Member Engagement, Coding Audit, and Chart Outreach
Coordinate provider targeting and outreach strategies, resolve documentation and coding barriers, and align improvement efforts with enterprise risk adjustment and quality goals
Provide leadership with concise summaries and recommendations on provider performance trends, engagement effectiveness, and improvement opportunities