Sr. Risk Adjustment Analyst

 Central Coast Salary Range - $117,904 - $176,857

Job Summary

The Sr. Risk Adjustment Analyst will be responsible for supporting the end-to-end risk adjustment program for the CenCal Health Medicare Advantage D-SNP line of business.  This position plays a critical role in ensuring that policies and procedures are followed to achieve appropriate risk adjustment revenue from CMS, while ensuring compliance with CMS guidelines, and other regulatory requirements.  The analyst will collaborate across Finance, Operations, Compliance, and IT to support revenue accuracy, RADV risk mitigation, and encounter data integrity.

Duties and Responsibilities

The Sr. Risk Adjustment Analyst is responsible for the following job duties:

Key Responsibilities:

• Encounter Data Integrity

  • Support business processes for successful submission and reconciliation of encounter submissions to CMS/Medicare

  • Collaborate with IT, Operations, and vendors to ensure encounter data submissions are timely, accurate, and compliant with CMS requirements.

  • Assist in root-cause analysis of rejected/returned encounters and support corrective action plans.

  • Contribute to preparation for CMS audits and RADV reviews, ensuring complete documentation and compliance.

• Data Analysis & Reporting

  • Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines

  • Develop, maintain, and distribute recurring financial and operational risk adjustment reports (MMR, PPR, DTRR, etc.).

  • Monitor revenue trends and risk score impacts, identifying opportunities for improvement.

• Vendor Oversight & Compliance

• Monitor vendor performance relating to compliance standards and program financial success

• Coordinate data exchange with vendors and all external stakeholders

• Support the tracking and reporting for all CMS response files and reports, including MMR, MOR, MAO-002, and MAO-004 reports

• Support and participate in internal and external audits as needed

• Cross-Functional Support

  • • Partner with clinical, compliance, and vendor teams on initiatives that improve documentation and coding accuracy.

    • Provide ad hoc analysis and subject matter expertise to leadership on risk adjustment topics.

    • Support development and implementation of policies, procedures, and training related to risk adjustment data

Knowledge/Skills/Abilities

Skills:

• Familiarity with CMS-HCC or HHS-HCC risk adjustment models

• Experience with analyzing and visualizing large data sets

• Comprehensive knowledge of Microsoft Office applications, including Word, PowerPoint, Outlook, and Intermediate Excel skills

• Proficiency in data analysis and reporting, using tools such as SAS, Microsoft SQL Server, Oracle SQL Developer, Toad, Tableau and Power BI

• Understanding of CMS Medicare Regulatory Requirements

• Ability to establish and maintain positive professional working relationships, both within and outside CenCal Health

Additional Attribu