Analyst, Risk Adjustment

About the role

Risk Adjustment accounts for differences in members’ health needs and expected cost of care. Accurate and complete clinical documentation helps ensure that a member’s health status is appropriately represented. Prospective Risk Adjustment focuses on proactively supporting opportunities for healthcare providers to review members’ health information and accurately document conditions addressed during clinical care, in accordance with applicable clinical coding and documentation requirements. These efforts may include sharing relevant clinical information with providers at the point of care, conducting virtual or in-home health assessments, and providing reports that identify historical or suspected conditions for provider review and clinical validation.

The Analyst, Risk Adjustment supports the day-to-day execution and performance of Prospective Risk Adjustment programs. This role partners with internal teams and external vendors to ensure operational workflows are functioning as intended, program data and reporting are accurate, claims are processed appropriately, and operational issues are identified and resolved in a timely manner. The analyst will support a portfolio of initiatives including Point-of-Care tools, Virtual Health Assessments (VHA), In-Home Assessments (IHA), and provider reporting to support the review of member conditions.

You will report into the Sr. Manager, Strategic Initiatives (Risk Adjustment).

Responsibilities

• Prospective Risk Adjustment Program Operations (30%) – Support daily operations across prospective Risk Adjustment programs, including Point-of-Care tooling, VHA, IHA, and provider gap-reporting initiatives. Monitor program activity and workflows to ensure processes are functioning as intended; investigate operational issues and coordinate resolution or escalation as appropriate.
• Vendor Operations & Support (25%) – Support the day-to-day operational needs of external vendors. Coordinate recurring deliverables and data exchanges, respond to operational questions, track issues and action items, and partner with vendors and internal stakeholders to drive timely resolution.
• Reporting, Data Analysis & Reconciliation (20%) – Develop and maintain recurring reports, trackers, and analyses to monitor program performance, including assessment activity, provider participation, vendor performance, claims activity, and other key operational metrics. Perform data validation and reconciliation across internal and vendor data sources to identify discrepancies, trends, and opportunities for operational improvement.
• Point-of-Care & Provider Programs (15%) – Support programs that provide relevant member health information, including historical and suspected conditions, to healthcare providers for review and clinical validation. Support Point-of-Care tools and provider reporting initiatives and assist with resolving related data, reporting, and workflow issues.
• Member & Claims Operations (10%) – Support member-level program operations, including reviewing and processing appropriate exclusions from VHA and IHA programs. Monitor and reconcile claims associated with prospective Risk Adjustment initiatives to ensure appropriate processing and payment; investigate discrepancies and partner with relevant teams to support resolution.

Requirements

• Strong analytical and problem-solving skills, with the ability to investigate operational or data-related issues and support resolution.
• Strong attention to detail and organizational skills, with the ability to manage multiple priorities and recurring deliverables.
• Ability to work effectively with data, reporting tools, spreadsheets, and operational workflows.
• Strong written and verbal communication skills with the ability to collaborate effectively across teams and with external partners.

Bonus points

• Knowledge of healthcare operations, Risk Adjustment, claims, provider operations, or health plan processes.
• Experience analyzing data, identifying trends or discrepancies, and translating findings into actionable next steps.
• Proficiency with Excel or Google Sheets; familiarity with SQL, Tableau, Looker, or similar analytics tools is a plus.

Work experience

• Experience within a health plan, provider organization, healthcare technology company, or other healthcare environment.
• Exposure to prospective Risk Adjustment programs, health assessments, Point-of-Care workflows, provider gap programs, healthcare claims, or vendor operations.

Education

• Bachelor’s degree in a healthcare, business, analytical, or related discipline preferred.