Risk Adjustment Solutions Analyst

ABOUT ADVANTMED

Advantmed is a leading provider of risk adjustment, quality improvement, and value-based solutions to health plans and providers. We drive market leading performance with integrated technology, service, and program solutions that improve the risk adjustment and quality programs of our partners. Our solutions focus on identifying, managing, and documenting risk and quality performance, and the proactive clinical engagement of high acuity populations.

About the Role

• We are seeking a highly motivated and experienced Risk Adjustment Specialist to join our growing Data Analytics team. This role is ideal for a healthcare analytics professional with deep expertise in Medicare Advantage, ACA Risk Adjustment, CMS data, and healthcare analytics.
• The successful candidate will serve as a trusted subject matter expert, partnering with clients, operations, technology, and leadership teams to transform complex healthcare data into actionable insights that drive Risk Adjustment performance, improve operational efficiency, and support strategic decision-making.

Key Responsibilities

Risk Adjustment Analytics & Strategy

• Analyze Medicare Advantage and ACA Risk Adjustment program performance to identify opportunities for RAF improvement and revenue optimization.
• Provide expertise on CMS-HCC, RxHCC, Medicare Risk Adjustment methodologies, and industry best practices.
• Evaluate operational and financial performance metrics and develop data-driven recommendations.
• Support client-facing initiatives, business reviews, and executive presentations.

Healthcare Data Analysis

• Analyze, cleanse, transform, reconcile, and validate large healthcare datasets from multiple sources.
• Perform analysis across Claims, Encounters, Eligibility, Pharmacy, Medical Record Review (MRR), and Health Assessment datasets.
• Identify trends, anomalies, and opportunities through detailed data analysis.
• Conduct root cause analysis and recommend corrective actions to improve data integrity and operational performance.

CMS Data Management & Reporting

• Work extensively with CMS data sources, including MMR, MOR, and other Medicare Advantage datasets.
• Support Risk Adjustment reconciliation, forecasting, and financial impact analysis.
• Develop operational reports, scorecards, ad hoc analyses, and executive dashboards.
• Translate complex analytical findings into meaningful business recommendations.