What are the responsibilities and job description for the Risk Adjustment Analyst position at CSTS Customer Service and Technology Solutions LLC?
Job Title: Risk Adjustment Analyst
Position Summary:
We are seeking a highly analytical and detail-oriented Risk Adjustment Analyst to support our organization’s Medicare Advantage, ACO REACH, ACA, and other risk-based programs. This role is critical in reporting, trend analysis, RAF analytics, and provider opportunity targeting. The ideal candidate understands CMS risk-adjustment methodologies, coding impacts, and can turn data insights into actionable strategies for coding, CDI, and clinical teams.
Experience with RADV audits and compliance is strongly preferred.
Key Responsibilities:
Risk Adjustment Analytics & Reporting
- Develop and deliver recurring and ad-hoc reports on RAF trends, HCC capture rates, provider performance, and suspect lists.
- Analyze large datasets (claims, EHR, encounter files) to identify gaps and missed opportunities.
- Monitor RAF impacts, HCC prevalence, V28 mapping changes, and quality indicators.
- Build dashboards and visualizations using Excel, Power BI, Tableau, or similar tools.
- Provide actionable insights to support coding, CDI, and provider education.
Provider Targeting & Opportunity Identification
- Create provider-level opportunity lists for chronic conditions, recapture needs, and care gaps.
- Collaborate with CDI, coding, and provider relations teams to prioritize outreach strategies.
- Analyze documentation trends and recommend workflow improvements.
Trend Monitoring & Forecasting
- Evaluate RAF projections and support financial modeling and risk analysis.
- Conduct year-over-year HCC trend reviews and measure program effectiveness.
RADV Preparation & Compliance (Preferred)
- Assist with RADV audit readiness, documentation validation, and compliance workflows.
- Review charts for CMS RADV compliance and error-risk mitigation.
Required Qualifications:
- Bachelor’s degree in Health Informatics, Data Analytics, Public Health, Business, or related field (or equivalent experience).
- 2 years in risk adjustment analytics, RAF modeling, or healthcare data analysis.
- Strong understanding of ICD-10-CM, HCC coding, V28 models, and risk-adjustment methodologies.
- Proficiency in Excel (advanced), SQL, Python, R, or BI tools (Power BI, Tableau).
- Ability to analyze complex datasets and present actionable insights.
- Excellent communication skills for non-technical audiences.
Preferred Qualifications:
- Experience with RADV audits and CMS compliance.
- Prior work in payer, ACO, MSO, or risk-bearing provider group.
- Familiarity with encounter submission workflows and suspecting models.
- Knowledge of EHR systems and coding/CDI platforms (Inovalon, Cotiviti, Apixio, Optum).
Why Join Us?
- High-impact role influencing organizational RAF performance and financial strength.
- Work cross-functionally with coding, CDI, providers, and leadership.
- Hands-on work with meaningful data that shapes strategy and improves care outcomes.
Pay: $80,000.00 per year
Work Location: Remote
Salary : $80,000