Principal Risk Adjustment & Revenue Integrity Analytics Lead

Lumeris Inc.; United States; Remote; USD 133,000 - 181,000; Full time

Benefits offered by this job

Medical, Vision and Dental Plans

401k with company match

Paid Time Off

Job summary

Lumeris Inc. is seeking a Principal Risk Adjustment & Revenue Integrity Analytics Lead to design, build, validate, and operationalize Medicare Advantage analytics.

You will own the analytics assets, harmonize data from claims, encounters, and CMS sources, and translate findings into actionable business insights for executive leadership. You will partner with the VP and Senior Director to align analytic models with business operations, drive proactive risk/revenue intelligence, and scale

Qualifications

• Bachelor's degree in Mathematics, Statistics, CS, Data Analytics, Health Informatics, Finance or Actuarial Science.
• 8+ years in healthcare analytics with Medicare Advantage risk adjustment experience.
• Experience with RAF, CMS-HCC, and risk-adjusted payment performance.
• Experience with risk adjustment data flows and model validation.
• Ability to forecast and reconcile performance across bids, budgets and actuals.
• Proficient in SQL and dashboarding tools (Power BI/Tableau).
• Strong communication to senior leadership.

Responsibilities

• Build and own risk adjustment analytic truth: dashboards and reporting for Part C/D.
• Forecast RAF, Bid/Budget, and revenue; analyze variances with documented drivers.
• Trace diagnosis-to-payment lifecycle to create reconciliation controls.
• Identify, size, and track recovery opportunities with ROI clarity.
• Drive risk adjustment performance with internal teams and stakeholders.
• Automate recurring reporting with scalable dashboards and SQL assets.
• Own domain business logic and data quality criteria for trustworthiness.
• Translate complex analytics into executive narratives for leadership.
• Monitor CMS regulation and quantify its impact on data and forecasts.

Skills

Risk Adjustment

Forecasting

SQL

Dashboarding

Data validation

QA controls

AI analytics

Communication

Modeling

Leadership

Education

Bachelor's degree in a related field

Advanced degree preferred

Tools

Power BI

Tableau

Job description

Welcome

Your Future is our Future At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact. We're excited to consider every qualified candidate authorized to work in the United States, although we are unable to sponsor visas for this role at this time.

Position:

Principal Risk Adjustment & Revenue Integrity Analytics Lead

Position Summary

The Principal Risk Adjustment & Revenue Integrity Analytics Lead is a senior, hands-on analytics leader responsible for designing, building, validating, and operationalizing Medicare Advantage Part C risk adjustment analytics. Reporting directly to the Senior Director of Health Plan Analytics, this role directly supports the Medicare Advantage plans of Essence Healthcare, serving as the analytic truth owner for Risk Adjustment by connecting risk-score performance, diagnosis and HCC capture, encounter submissions, and revenue impact into a single, trusted operating model. The lead will partner closely with the VP of Risk Adjustment Solutions and Strategy to align technical analytic models with overall business operations and strategic interventions. The lead is expected to work independently, translating complex data from claims, encounters, eligibility, and CMS sources into actionable performance intelligence. This individual will act as a senior builder and strategic partner to Risk Adjustment, Finance, Actuarial, and other key departments. The ideal candidate will be a domain owner who can distinguish the drivers of financial performance—whether it's population mix, model changes, or operational execution—and establish an auditable fact base for action. This role is pivotal in shifting the function from retrospective reporting to proactive risk and revenue intelligence.

Primary Responsibilities

• Build and Own Risk Adjustment Analytic Truth: Design, build, and maintain the primary analytic assets, dashboards, and reporting for Part C and Part D risk-score performance.
• Forecast Part C RAF, Bid/Budget Performance, and Revenue: Develop and maintain risk-score and revenue forecasting models, comparing projections to actuals and decomposing any variances into documented drivers.
• Reconcile the Diagnosis-to-Payment Lifecycle: Trace diagnoses and HCCs from source to payment, analyzing submission and response data (e.g., EDPS, MAO-004) to create repeatable reconciliation controls.
• Identify, Size, and Track Recovery Opportunities: Analyze and track opportunities such as recapture and chart reviews using documented valuation rules, ensuring clear ROI visibility and preventing double counting.
• Drive Risk Adjustment Provider, Vendor, and Operational Performance: Partner with internal teams to prioritize high-impact opportunities and measure performance by provider, program, vendor, and intervention.
• Automate and Scale Risk Adjustment Intelligence: Automate recurring reporting to reduce manual effort through scalable dashboards, reusable SQL, documented business logic, and repeatable processes.
• Own Risk Adjustment Business Logic and Data Trustworthiness: Own the domain's business logic, metric definitions, and data quality criteria to ensure all reporting is accurate, reproducible, and fit for executive use.
• Communicate Executive-Ready Performance Narratives: Translate complex model, coding, and financial logic into clear, decision-ready narratives for leadership and non-technical stakeholders.
• Monitor CMS Regulation & Quantify Impact: Serve as a senior subject matter expert on Medicare Advantage Risk Adjustment, monitoring regulatory changes and quantifying their impact on the organization’s data, forecasts, and operations.

Qualifications

• Bachelor's degree in a related field such as Mathematics, Statistics, Computer Science, Data Analytics, Health Informatics, Finance, or Actuarial Science.
• 8+ years of healthcare analytics experience, with direct experience in Medicare Advantage Part C Risk Adjustment, RAF, CMS-HCC, and risk-adjusted payment performance.
• Demonstrated experience analyzing Part C risk-score performance, including model impacts, coding trends, population mix, and submission outcomes.
• Experience with Risk Adjustment data flows, including claims/encounters, eligibility, provider data, supplemental files, EDPS, MAO-004, and MMR/payment data.
• Ability to build and reconcile forecast-to-actual performance across Bid, Budget, projections, and final reconciliation.
• Hands-on experience writing complex SQL to extract and reconcile data from large-scale data environments.
• Experience building dashboards and automated reports using tools like Power BI or Tableau.
• Experience designing validation, QA, and reconciliation controls for high-stakes financial or healthcare analytics.
• Experience using AI-enabled analytics, automation, or advanced statistical tools to accelerate insight generation.
• Ability to self-direct analyses, manage ambiguity, and deliver actionable insights with limited direction.
• Strong communication skills with the ability to explain complex drivers to senior leadership.

Preferred

• Advanced degree in Analytics, Economics, Health Informatics, Finance, Actuarial Science, Business Administration, or a related field.
• Experience with Part D risk-score analytics, PDE, coding/chart-review programs, provider risk arrangements, or using Python/R for advanced analytics.

Working Conditions

While performing the duties of this job, the employee works in normal office working conditions. #LI-REMOTE

Pay Transparency

Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.

Salary Range

The hiring range for this position is: $133,200.00-$180,900.00

Benefits of working at Lumeris

• Medical, Vision and Dental Plans
• Tax-Advantage Savings Accounts (FSA & HSA)
• Life Insurance and Disability Insurance
• Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
• Employee Assistance Program
• 401k with company match
• Employee Resource Groups
• Employee Discount Program
• Learning and Development Opportunities
• And much more...

Member Facing Position

No- Not Member or Patient Facing Position

Drug Screen Requirement

No

MVR Required

No

Credit Check Required

No

Location

Remote, USA

Time Type

Full time

EEO statement

Lumeris is an EEO/AA employer M/F/V/D

Disclaimer

The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential job duties and responsibilities.

Why Join Lumeris?

Lumeris is bringing common sense back to the business of healthcare by empowering value-based care. We create the partnerships and perspectives that are making healthcare safer, more affordable and more personalized for providers, patients and payers alike. We were founded on the belief that it should be easier to provide the right care, at the right time, at the right cost. Our model is bringing that belief to life, improving outcomes and empowering financial sustainability along the way.

Join Our Growing Team!

We create a community that values its people and empowers you to make an impact.