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Risk Adjustment Analyst

JOB TITLE: Risk Adjustment Analyst
DEPARTMENT: Risk Adjustment
JOB TYPE: Full Time
REPORTS TO: Senior Director of Risk Adjustment

Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

HealthOne is guided by a cultural framework that embodies our values and drives our decisions.

Our PURPOSE is to care for people by connecting them to resources that help protect them in health-related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.

The Risk Adjustment Analyst designs and implements data architecture to enable rapid analysis and generation of clinical, strategic, and financial insights to ensure risk scores and related revenue align with the associated risk of insured using various techniques, such as statistical analysis, explanatory and predictive modeling, and data mining. The Risk Adjustment Analyst will research best practices and support developing the solutions and recommendations for data submission, data integrity, and calculation of key performance metrics.

• Assists in submitting encounter, enrollment, and supplemental data to EDGE server per CMS requirement. Analyzes the response files and corrects any errors in the submission.
• Develops and maintains databases and dashboards that support various Risk Adjustment KPIs at various cadences.
• Collaborates regularly with internal departments, including Finance, Government Programs, Network Management, Provider Contracting, Analytics, and external vendors on risk adjustment projects.
• Calculates ROI for risk adjustment vendors, initiatives, and projects.
• Works to identify coding gaps in the claims, pharmacy data and the encounter reconciliation process through the development of SQL code queries.
• Supports RADV audit analytics.
• Maintains current knowledge of CMS’ Hierarchical Condition Categories (HCC) and Prescription Drug Risk Adjustment codes (RxHCCs) including risk adjustment values and formulas.
• Maintains current knowledge of EDGE Server business rules and related regulatory requirements.
• Provides insight and analysis for plan design and development to support risk adjustment activities.
• Develops and maintains monthly, quarterly, and annual risk adjustment reports as required for statutory, financial, and regulatory reporting.
• Participates in the data error identification efforts and coordinates error resolutions with key stakeholders, such as claims, enrollment, and pharmacy.
• Performs root cause analysis on emerging issues.
• Maintains regular and predictable attendance.
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice.
• Works to encourage and promote Company culture throughout the organization.
• Other duties may be assigned.

• Bachelor’s Degree in Statistics, Accounting, Mathematics, Computer Science, Business, or related field
• One to three years’ health plan experience preferred.
• Understanding of statistical methods, with programming experience in R or SAS preferred
• Intermediate to Advanced proficiency with SQL
• Familiarity with insurance terms and concepts
• Advanced Microsoft Excel skills
• Excellent communication skills

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.


401K (4% Match, Immediate Vesting)
Accident insurance
Competitive salary
Critical Illness Insurance
Dental Insurance
Employee Assistance Program
Flexible Spending Account
Health & Wellness Program
Health Savings Account
Life & AD&D Insurance
Long Term Disability
Medical Insurance
Paid Time Off
Pet Insurance
Short Term Disability
Vision Insurance

Drug Screen and Background Check Required

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status or any other status protected by state or federal law.

Time:  Full time
Salary:  Salary
Category:  Administration

Updated: 4/10/2024 12:48:22 PM

Job Contact:
Nelly Maldonado

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201 W Waugh St
Dalton, GA 30720