CMS Edge Server / Risk Adjustment Data Architect Healthplan
About The Position
Huron helps healthcare organizations drive growth, enhance performance, and sustain leadership in an increasingly complex healthcare environment. Within our HDTx Payer Services practice, we partner with health plans to modernize operations, optimize regulatory reporting, improve data quality, and enable data-driven decision making. We are seeking an experienced CMS EDGE Server / Risk Adjustment Data Architect to serve as a strategic technical advisor and hands-on architecture lead for healthcare payer clients. This individual will bring deep expertise in CMS EDGE Server operations, ACA risk adjustment, reinsurance, payer data platforms, and regulatory reporting architecture. The ideal candidate will design and guide scalable, compliant CMS EDGE Server solutions that support accurate submission of membership, claims, encounter, supplemental diagnosis, and other CMS-facing data while partnering closely with business, compliance, actuarial, operations, and technology stakeholders.
Requirements
- 7+ years of healthcare payer experience with strong exposure to ACA, risk adjustment, reinsurance, regulatory reporting, and payer data operations.
- Deep hands-on experience with CMS EDGE Server architecture, implementation, operations, configuration, data submission workflows, and production support.
- Strong understanding of CMS/HHS requirements, ACA EDGE Server reporting, risk adjustment transfer payment processes, reinsurance reporting, and regulatory submission timelines.
- Experience designing or supporting data pipelines and interfaces across payer source systems, claims platforms, encounter processing, membership/eligibility systems, and CMS-facing reporting environments.
- Proven ability to define technical architecture, data mapping, validation rules, reconciliation logic, exception reporting, and operational controls for CMS EDGE Server submissions.
- Experience working directly with health plan stakeholders, technology teams, vendors, and compliance partners in client-facing advisory or consulting environments.
- Strong documentation, communication, facilitation, and executive stakeholder management skills, with the ability to explain technical issues to business and compliance audiences.
Nice To Haves
- Experience with Cognizant CMS EDGE Server, ClaimSphere, Facets (TriZetto), HealthRules, QNXT, or other payer core administration and reporting platforms.
- Experience with SQL, data analysis, data profiling, ETL/ELT concepts, data lineage, exception reporting, and healthcare data quality management.
- Knowledge of Medicare Advantage, Medicaid, commercial exchange, HEDIS, CMS STARs, encounter data, risk adjustment analytics, or quality reporting programs.
- Experience creating product roadmaps, solution designs, implementation plans, user stories, test plans, operational readiness materials, and governance reporting.
- Familiarity with Agile delivery, Jira, Azure DevOps, Confluence, Power BI, Visio, Lucidchart, or similar tools used to manage complex payer technology initiatives.
Responsibilities
- Serve as the – CMS EDGE Server / Risk Adjustment Data Architect and subject matter expert for ACA risk adjustment, reinsurance, and CMS regulatory reporting initiatives.
- Design and oversee end-to-end CMS EDGE Server architecture, including source system integration, data ingestion, transformation, validation, reconciliation, submission readiness, and error resolution processes.
- Lead CMS EDGE Server implementations, upgrades, enhancements, production support, and operational stabilization efforts for payer clients.
- Translate CMS/HHS reporting requirements, business rules, and regulatory updates into scalable technical designs, solution roadmaps, data specifications, and implementation plans.
- Partner with payer business, actuarial, risk adjustment, compliance, data engineering, IT, and vendor teams to align CMS EDGE Server capabilities with operational and regulatory objectives.
- Define and improve data quality controls across membership, eligibility, claims, encounter, provider, and supplemental diagnosis data to support accurate and audit-ready CMS submissions.
- Perform root-cause analysis on submission errors, data defects, reconciliation gaps, and downstream reporting issues; recommend and guide remediation strategies.
- Develop architecture documentation, data flow diagrams, business and technical requirements, user stories, acceptance criteria, and operational playbooks for CMS EDGE Server processes.
- Provide client-facing advisory support on CMS EDGE Server best practices, implementation risks, reporting timelines, data governance, and production readiness.
Benefits
- medical, dental, and vision coverage to employees and dependents
- a 401(k) plan with a generous employer match
- an employee stock purchase plan
- a generous Paid Time Off policy
- paid parental leave and adoption assistance
- Wellness Program supports employee total well-being by providing free annual health screenings and coaching, bank at work, and on-site workshops, as well as ongoing programs recognizing major events in the lives of our employees throughout the year.
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What This Job Offers
Career Level
Senior
Education Level
No Education Listed
