Risk Adjustment - Risk Adjustment Data Analyst II 135-2008

CommunityCare•Tulsa, OK

18d

About The Position

The Risk Adjustment Data Analyst II supports CommunityCare’s Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs by managing data submissions, developing reporting, and delivering actionable analytics. The role ensures the accuracy and integrity of encounter and risk score data, including RAF reporting for MA and PLRS reporting for ACA. The analyst also serves as a subject matter resource for risk adjustment data, submissions, and reporting, and mentors junior analysts.

Requirements

Ability to apply advanced mathematical and statistical techniques to healthcare and risk adjustment data analysis for MA and ACA.
Ability to independently manage work, prioritize competing demands, and complete projects with minimal supervision.
Strong oral and written communication skills and ability to present data, insights, and findings to diverse audiences.
Knowledge of programming, including writing, modifying, and optimizing queries; SQL is preferred.
Knowledge of healthcare data, including claims, encounters, enrollment, and provider data, and understanding of risk adjustment processes and data flows.
Working knowledge of Medicare Advantage and/or ACA risk adjustment methodologies, including HCC models, encounter submissions, and/or EDGE/PLRS reporting processes.
Strong analytical, critical-thinking, and problem-solving skills, including root cause analysis and data validation.
Successful completion of a Health Care Sanctions background check.
Bachelor’s degree required.
Demonstrated use of analytical tools such as SAS or SQL.
At least three years of health data analysis experience.

Nice To Haves

Degree in Mathematics, Statistics, Economics, Actuarial Science, or another quantitative discipline.
Master’s degree.
Experience analyzing CMS and/or ACA response files, submission errors, and reconciliation outputs.
Proficiency with Microsoft Office applications, including Excel.
Experience with Power BI, Tableau, or similar visualization tools.
Two or more years of risk adjustment experience.

Responsibilities

Manage CMS encounter submissions and ACA data processes, including EDGE/PLRS reporting.
Validate and reconcile data, conduct root cause analysis, and resolve variances between submitted data and CMS-accepted data.
Analyze submission errors, response files, and rejection trends to improve data quality and acceptance rates.
Develop and maintain risk score reports, KPIs, and dashboards covering RAF, PLRS, enrollment, drivers, and population trends.
Prepare monthly production and performance reports across retrieval, coding, and vendor operations.
Support retrospective chart reviews and RADV activities, including developing chase lists.
Write complex SQL queries and integrate data from claims, encounters, enrollment, pharmacy, and vendor sources.
Partner with vendors and internal teams to improve data quality, reporting, and operational performance.
Analyze CMS response files such as MAO-004 and monthly membership reports (MMR); ensure conditions are captured, reported accurately, and accepted by CMS systems; identify trends and potential new initiatives.
Mentor and support junior analysts to promote consistency and best practices.
Translate data into actionable business insights and recommend process improvements.
Serve as a subject matter resource for risk adjustment data, submissions, and reporting.
Perform other job-related duties as required or assigned.