Data Analyst, Risk Adjustment

Risk Adjustment Data Analyst

Responsibilities

• The Risk Adjustment Data Analyst supports end to end risk adjustment and revenue cycle operations by analyzing HCC submissions by ArchWell Health and any rejections at Clearninghouse/payer/CMS level, managing chart retrieval and review workflows, and ensuring accurate ingestion of care gap and clinical documentation data for various sources.
• This role is critical to maintaining RAF accuracy, reducing submission errors, and enabling continuous monthly reconciliation across MA programs.
• The role requires flexibility to perform additional tasks as needed, especially as risk adjustment and quality requirements evolve across markets and programs.

HCC Reconciliation & Submission Validation

• Perform monthly validation of all HCC submissions (MAO004, encounters, claims, sweeps).
• Analyze payer acceptance, rejections, and 277CA/999 acknowledgement files.
• Identify new, recaptured, and dismissed HCCs and reconcile against internal systems (VIM, HCC engine).
• Present and route any rejections/gaps for appropriate teams.

Sweeps & Payer Data Management

• Review sweeps datasets to ensure completeness, accuracy, and payer acceptance.
• Support ASM workflows and monitor acceptance/rejection trends.
• Track payer healthcare gaps and validate alignment with internal care gap logic.

Chart Retrieval & Review Support

• Build and maintain chart retrieval/review prioritization rules (1LR, 2LR, external providers).
• Monitor chart retrieval programs, turnaround times, and vendor performance.
• ROI analysis of various programs
• Manage unlinked charts and ensure proper linkage to members, service dates, and HCCs.

Care Gap & Clinical Data Ingestion

• Support ingestion/analysis health plan care gap files and ensure accurate mapping into VIM and analyze suspects conversion rate from various sources.
• Validate care gap completeness and partner with clinical teams to ensure data is actionable.
• Develop or refine member stratification logic for outreach and in home visit prioritization.
• Build/Maintain dashboards and reports to track HCC operations work inclusive of reconciliation, chart retrieval progress, and rejection trends.
• Provide insights to leadership on productivity, throughput, and operational bottlenecks at market/center/payer level.
• Support continuous improvement by identifying recurring issues and recommending process enhancements.
• Work closely with Operations, RCM, Coding, Clinical Documentation, Vendor partners, and IT/Data teams.
• Participate in governance meetings to review trends, exceptions, and payer specific issues.
• Ensure alignment across teams to reduce sweeps level escalations and maintain steady state workflows.

Requirements

• Bachelor’s degree in Healthcare Administration, Data Analytics, Public Health, or related field.
• 3-5 years of experience in risk adjustment, RCM, healthcare analytics, or payer operations.
• Strong understanding of HCCs models, RAF, MAO004, 277CA/999/835 files, and encounter submission workflows.
• Deep experience with SQL, Excel, and data visualization tools (Power BI, Tableau).
• Ability to interpret clinical documentation and coding outputs (ICD 10, HCC mapping).
• Strong analytical, problem solving, and communication skills.
• Detail oriented with strong data validation skills
• Ability to manage multiple workstreams and deadlines
• Strong cross functional collaboration
• Comfort working in fast paced, evolving operational environments
• Commitment to accuracy, compliance, and documentation integrity

Preferred

• Experience working with chart retrieval vendors or clinical documentation teams preferred.