Remote Senior Risk Adjustment & Revenue Analytics Lead

Lumeris; United States; À distance; USD 133 000 - 181 000; Plein temps

Avantages offerts par ce poste

Medical, Vision and Dental Plans

401k with company match

Paid Time Off

Learning and Development Opportunities

Employee Discount Program

Résumé du poste

Lumeris is seeking a Principal Risk Adjustment & Revenue Integrity Analytics Lead to design, build, and operationalize Medicare Advantage risk-adjustment analytics. You will own the analytic truth for RAF performance and connect diagnosis, HCC capture, and revenue impact in a single model.

You will forecast Part C RAF, reconcile diagnosis-to-payment lifecycles, automate reports, and partner with Finance, Actuarial, and Risk Adjustment teams to drive proactive insights.

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.
• 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.

Responsabilités

• 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 variances.
• Reconcile the Diagnosis-to-Payment Lifecycle: Trace diagnoses and HCCs from source to payment, analyzing submission and response data to create repeatable reconciliation controls.
• Identify, Size, and Track Recovery Opportunities: Analyze and track opportunities such as recapture and chart reviews with ROI visibility.
• Drive Risk Adjustment Provider, Vendor, and Operational Performance: Partner with internal teams to prioritize high-impact opportunities and measure performance.
• Automate and Scale Risk Adjustment Intelligence: Automate recurring reporting to reduce manual effort through scalable dashboards and reusable SQL.
• Own Risk Adjustment Business Logic and Data Trustworthiness: Own domain business logic, metric definitions, and data quality criteria.
• Communicate Executive-Ready Performance Narratives: Translate complex model, coding, and financial logic into clear narratives for leadership.
• Monitor CMS Regulation & Quantify Impact: Monitor regulatory changes and quantify impact on data, forecasts, and operations.

Connaissances

Healthcare analytics

Risk Adjustment

Forecasting

SQL

Dashboards

Power BI

Tableau

Communication

Strategic thinking

Formation

Bachelor's degree in Mathematics/Statistics/CS/Analytics/Finance

Advanced degree preferred

Outils

SQL

Power BI

Tableau

Description du poste

Lumeris is seeking a Principal Risk Adjustment & Revenue Integrity Analytics Lead to design, build, and operationalize Medicare Advantage risk-adjustment analytics. You will own the analytic truth for RAF performance and connect diagnosis, HCC capture, and revenue impact in a single model.

You will forecast Part C RAF, reconcile diagnosis-to-payment lifecycles, automate reports, and partner with Finance, Actuarial, and Risk Adjustment teams to drive proactive insights.