Data Analyst, Risk Adjustment

ArchWell Health•Nashville, TN

About The Position

The Risk Adjustment Data Analyst supports end-to-end risk adjustment and revenue cycle operations by analyzing HCC submissions made by ArchWell Health and investigating rejections at the clearinghouse, payer, or CMS level. The role manages chart-retrieval and review workflows and supports accurate ingestion of care-gap and clinical documentation data from various sources. It helps maintain RAF accuracy, reduce submission errors, and enable continuous monthly reconciliation across Medicare Advantage programs. The role may include additional tasks as risk-adjustment and quality requirements evolve across markets and programs. The analyst validates HCC submissions, reviews payer acceptance and rejection files, identifies and reconciles HCC changes, and supports sweeps and payer-data workflows. The role also maintains chart-retrieval prioritization and monitoring, supports care-gap data ingestion and member stratification, and develops dashboards and reports that inform operational leaders. It involves close collaboration with operations, revenue cycle management, coding, clinical documentation, vendors, and IT/data teams.

Requirements

Bachelor’s degree in Healthcare Administration, Data Analytics, Public Health, or a related field.
3–5 years of experience in risk adjustment, revenue cycle management, healthcare analytics, or payer operations.
Strong understanding of HCC models, RAF, MAO004, 277CA/999/835 files, and encounter submission workflows.
Deep experience with SQL, Excel, and data visualization tools such as Power BI or Tableau.
Ability to interpret clinical documentation and coding outputs, including ICD-10 and HCC mapping.
Strong analytical, problem-solving, and communication skills.
Attention to detail and strong data-validation skills.
Ability to manage multiple workstreams and deadlines.
Strong cross-functional collaboration skills.
Comfort working in fast-paced, evolving operational environments.
Commitment to accuracy, compliance, and documentation integrity.

Nice To Haves

Experience working with chart-retrieval vendors or clinical documentation teams.

Responsibilities

Perform monthly validation of HCC submissions, including MAO004, encounters, claims, and sweeps.
Analyze payer acceptance, rejections, and 277CA/999 acknowledgment files.
Identify new, recaptured, and dismissed HCCs and reconcile them against internal systems, including VIM and the HCC engine.
Present and route submission rejections and gaps to appropriate teams.
Review sweeps datasets for completeness, accuracy, and payer acceptance; support ASM workflows and monitor acceptance and rejection trends.
Track payer healthcare gaps and validate alignment with internal care-gap logic.
Build and maintain chart-retrieval and review prioritization rules, including 1LR, 2LR, and external providers.
Monitor chart-retrieval programs, turnaround times, and vendor performance, and conduct ROI analysis of programs.
Manage unlinked charts and ensure proper linkage to members, service dates, and HCCs.
Support ingestion and analysis of health-plan care-gap files, ensure accurate mapping into VIM, and analyze suspect conversion rates from various sources.
Validate care-gap completeness and partner with clinical teams to ensure data is actionable.
Develop or refine member-stratification logic for outreach and in-home visit prioritization.
Build and maintain dashboards and reports tracking HCC operations, reconciliation, chart-retrieval progress, and rejection trends.
Provide leadership with insights on productivity, throughput, and operational bottlenecks at market, center, and payer levels.
Identify recurring issues and recommend process improvements.
Collaborate with Operations, RCM, Coding, Clinical Documentation, vendor partners, and IT/Data teams.
Participate in governance meetings to review trends, exceptions, and payer-specific issues.
Coordinate across teams to reduce sweeps-level escalations and maintain steady-state workflows.
Perform additional tasks as risk-adjustment and quality requirements evolve.