Senior 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.
• Technical & Cross-Functional Collaboration
• Develop, optimize, and troubleshoot complex SQL queries, stored procedures, and data extraction processes.
• Debug existing reporting and analytical scripts.
• Collaborate with business, operations, technology, and analytics teams to implement scalable solutions.
• Support automation, process improvement, and operational excellence initiatives.

Requirements

• Education
• Bachelor's degree in Healthcare, Statistics, Computer Science, Engineering, Business Analytics, or related field.
• Experience
• 5+ years of healthcare data analytics experience, including data mining, mapping, transformation, validation, and reporting.
• 3+ years of hands-on experience in Medicare Advantage and/or ACA Risk Adjustment.
• 3+ years of experience as a Healthcare Data Analyst.
• 3+ years of advanced SQL development experience.
• Healthcare & Risk Adjustment Expertise
• Strong understanding of Medicare Advantage and ACA Risk Adjustment programs
• CMS-HCC and RxHCC models
• Medical Record Review (MRR) and Health Assessment processes
• Claims, Encounter, Eligibility, and Pharmacy data
• CMS data files, including MMR and MOR
• End-to-end Risk Adjustment lifecycle
• HEDIS and healthcare quality measures
• Technical Skills
• Advanced SQL and Microsoft SQL Server
• SQL Server Management Studio (SSMS)
• Data mapping, reconciliation, and validation
• Root cause analysis and data quality management
• Ad hoc reporting and data extraction
• Professional Skills
• Strong analytical and problem-solving abilities
• Excellent communication and presentation skills
• Experience working directly with clients and executive stakeholders
• Ability to independently manage multiple priorities in a fast-paced environment

Preferred Qualifications

• Experience supporting Medicare Advantage health plans, provider groups, or Risk Adjustment vendors.
• Experience with Power BI, Tableau, or other Business Intelligence platforms.
• Knowledge of Risk Adjustment financial forecasting and revenue analytics.
• Experience leading client solutioning discussions and strategic initiatives.
• Exposure to automation, process optimization, and operational excellence programs.
• Familiarity with FHIR, EMR/EHR integrations, and healthcare interoperability standards.

What You'll Bring

• Deep expertise in Risk Adjustment and healthcare analytics.
• Ability to convert complex healthcare data into actionable business insights.
• Strong client-facing and consultative skills.
• A continuous improvement mindset focused on operational excellence and innovation.
• The ability to work independently while collaborating effectively across teams.