Senior Risk Adjustment Analytics Lead (CMS-HCC & Vendors)

EmblemHealth; New York (NY); On-site; USD 77,000 - 149,000; Full time

Job summary

EmblemHealth seeks a senior Risk Adjustment Modeling lead to develop and optimize CMS-HCC, HHS-HCC, and RX-HCC models for MA and ACA plans. You will drive analytics to forecast vendor spend, premium revenue, and program efficiency, collaborating with leadership and external partners to align with shared risk initiatives.

You will shepherd complex projects from planning through implementation, ensuring timely delivery and strong stakeholder communication across enterprise risk, finance, product,

Qualifications

• Bachelor’s Degree.
• Master’s Degree in Health or Business Administration (Preferred)
• 5–8+ years of related, professional work experience (Required)
• Experience working with Government Sponsored Health Plans (Required)
• Experience working for a vendor or consultant working with Risk Adjustment Modeling, Bid Submissions (Required)
• Experience in a managed care environment or similar highly regulated industry (Preferred)
• Ability to understand and interpret information and to communicate ideas and information to all audiences (Required)
• Proficiency with Data Programming – SQL, Python, SAS (Required)
• Proficiency with Microsoft Suite - Word, Excel, PowerPoint, Outlook, Teams (Required)
• Detail oriented; ability to think independently and to identify and resolve issues and impediments to project success (Required)
• Excellent communication skills - verbal, written, interpersonal, negotiation; ability to build rapport and relationships (Required)

Responsibilities

• Responsible for building and maintaining internal CMS-HCC, HHS-HCC models, their output and analytics for our MA and ACA plans.
• Partner with leadership on the development of analytics that forecast vendor spend, premium revenue and efficiency of internal Risk Adjustment programs.
• Deliver Risk Adjustment modelling outputs that lead the strategic deployment of our vendors as well as reporting on their efficacy by shared risk/shared savings partners.
• Partner with External Vendors to gain market insights for NYS Medicaid and Essential Plan and develop models to track.
• Partner with the Actuarial Department on model validation and revenue forecasting for all lines of business.
• Track progress and communicate project status on a regular basis to all impacted parties.
• Work with project owners to develop, align, and refine program management oversight to maximize chances for successful delivery of projects.
• Responsible for communicating progress to Enterprise Risk Adjustment leadership and producing status reports presented to the broader Emblem Leadership across Finance, Product, and Provider Network.

Skills

Analytical skills

Stakeholder management

Detail oriented

Education

Bachelor’s Degree

Master’s Degree in Health or Business Administration

Tools

SQL

Python

SAS

Microsoft Office Suite

Job description

EmblemHealth seeks a senior Risk Adjustment Modeling lead to develop and optimize CMS-HCC, HHS-HCC, and RX-HCC models for MA and ACA plans. You will drive analytics to forecast vendor spend, premium revenue, and program efficiency, collaborating with leadership and external partners to align with shared risk initiatives.

You will shepherd complex projects from planning through implementation, ensuring timely delivery and strong stakeholder communication across enterprise risk, finance, product,