Risk Adjustment Data Analyst
Position Summary
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.
Key Responsibilities
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.
Reporting & Analytics
- 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.
Cross‑Functional Collaboration
- 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.
Qualifications
- 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.
- Experience working with chart‑retrieval vendors or clinical documentation teams preferred.
Competencies
- 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