Senior Risk Adjustment & Revenue Analytics Lead (Remote)

Lumeris; United States; Remote; USD 133.000 - 181.000; Vollzeit

Benefits dieser Stelle

Medical, Vision and Dental Plans

Tax-Advantage Savings Accounts (FSA &H

Life Insurance and Disability

Paid Time Off

Employee Assistance Program

401k with company match

Employee Resource Groups

Employee Discount Program

Learning and Development Opportunities

And much more

Zusammenfassung

Lumeris is seeking a Principal Risk Adjustment & Revenue Integrity Analytics Lead in the United States to own end-to-end risk adjustment analytics for Medicare Advantage Part C. You will design, build, validate, and operationalize analytics, linking RAF, HCC capture, and submissions into a trusted model.

You will partner with Finance, Actuarial, and Risk Adjustment teams to drive proactive insights. The role emphasizes automation, scalable dashboards, and clear executive communications to inform

Qualifikationen

• 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.

Aufgaben

• 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 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.
• 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: Monitor regulatory changes and quantify their impact on data, forecasts, and operations.

Kenntnisse

Risk adjustment analytics

SQL

Communication skills

Data analysis

Self-direction

Ausbildung

Bachelor’s degree in a related field

Tools

Power BI

Tableau

Python

R

Jobbeschreibung

Lumeris is seeking a Principal Risk Adjustment & Revenue Integrity Analytics Lead in the United States to own end-to-end risk adjustment analytics for Medicare Advantage Part C. You will design, build, validate, and operationalize analytics, linking RAF, HCC capture, and submissions into a trusted model.

You will partner with Finance, Actuarial, and Risk Adjustment teams to drive proactive insights. The role emphasizes automation, scalable dashboards, and clear executive communications to inform