Risk Adjustment - Risk Adjustment Data Analyst II 135-2008

Communitycare; Tulsa (OK); On-site; USD 65,000 - 95,000; Full time

Job summary

Communitycare seeks an experienced Risk Adjustment Analyst II to support Medicare Advantage and ACA risk adjustment programs. You will manage CMS encounter submissions, develop reporting and dashboards, and deliver actionable analytics to ensure data accuracy and program success.

The role involves SQL querying, data validation, and cross-functional collaboration with vendors to improve data quality and operational performance.

Qualifications

• Bachelor's degree in Mathematics, Statistics, Economics, Actuarial Science or other quantitative discipline required.
• Minimum of three years of Health Data analysis experience; two+ years in risk adjustment preferred.
• Demonstrated use of analytical tools such as SAS or SQL.
• Experience with Power BI, Tableau, or other visualization tools preferred.
• Strong analytical, critical thinking, and problem solving skills.

Responsibilities

• Manage CMS encounter submissions and ACA data processes including EDGE/PLRS reporting.
• Perform data validation, reconciliation, and root cause analysis to identify variances.
• Analyze submission errors, response files, and rejection trends to improve data quality.
• Develop and maintain risk score reporting and KPIs like RAF and PLRS.
• Prepare monthly production and performance reports across retrieval, coding, and vendor operations.
• Support RADV activities including chase list development.
• Write complex SQL queries across claims, encounters, enrollment, pharmacy, and vendor sources.
• Mentor junior analysts to promote consistency and best practices.
• Translate data into actionable business insights and serve as SME for risk adjustment reporting.

Skills

Statistical analysis

SQL querying

Data validation

Communication

Mentoring

Problem solving

Education

Bachelor’s degree in quantitative field

Master’s degree a plus

Tools

SAS

SQL

Power BI

Tableau

Job description

JOB SUMMARY:

The Risk Adjustment Analyst II supports the organization’s Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs by managing data submissions, developing reporting, and delivering actionable analytics. This role is responsible for ensuring the accuracy and integrity of encounter and risk score data, including RAF (MA) and PLRS (ACA) reporting.

KEY RESPONSIBILITIES:

• Manage Centers for Medicare & Medicaid Services (CMS) encounter submissions and ACA data processes including EDGE/PLRS reporting.
• Perform data validation, reconciliation, and root cause analysis to identify 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 reporting, key performance indicators (KPIs) and dashboards such as risk adjustment factor (RAF), plan liability risk score (PLRS), enrollment, drivers, population trends.
• Prepare monthly production and performance reports across retrieval, coding, and vendor operations.
• Support retrospective chart reviews and risk adjustment data validation(RADV) activities, including chase list development.
• Write complex SQL queries and integrate data across 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 being captured, reported accurately and accepted by CMS’s data systems;identifytrends in risk scores, enrollment, population segments and identifynew initiative opportunities.
• Mentor and support junior analysts to promote consistency and best practices across the team.

• Translate data into actionable business insights and proactively 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.

QUALIFICATIONS:

• Ability to apply advanced mathematical and statistical techniques to the analysis of healthcare and risk adjustment data (MA and ACA).
• Demonstrated ability to independently manage work, prioritize competing demands, and drive projects to completion with minimal supervision.
• Strong oral and written communication skills, with the ability to clearly present risk adjustment data, reporting insights, and findings to diverse audiences.
• Demonstrated knowledge of programming, including writing, modifying, and optimizing queries (SQL preferred).
• Demonstrated knowledge of healthcare data, including claims, encounters, enrollment, and provider data, with a strong 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.
• Experience analyzing CMS and/or ACA response files, submission errors, and reconciliation outputs preferred.
• Proficient in the use of Microsoft Office applications, including Excel preferred.
• Strong analytical, critical thinking, and problem-solving skills, with the ability to perform root cause analysis and data validation.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Bachelor’s degree required. Degree in Mathematics, Statistics, Economics, Actuarial Science or other quantitative discipline preferred. Master’s degree is a plus.
• Demonstrated use of analytical tools such as SAS or SQL.
• Experience with Power BI, Tableau, or other similar visualization tools preferred.
• A minimum of three years of Health Data analysis experience required. Two or more years of risk adjustment experience preferred.