Lead, Risk Adjustment - Predictive Analytics

Job Description

Job Summary

The Lead, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina’s Prospective and Retrospective Interventions. Provides technical, functional and business training to other team members to enable them to perform the tasks required.

Knowledge/Skills/Abilities

• Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions.
• Design and development ad-hoc as well as automated analytical modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP.
• Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses.
• Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost.
• Conduct root cause analysis for business data issues, report to leadership the summary of findings and resolutions.
• Design and lead development of tracking system for risk scores for all intervention outcome and for overall markets and LOB.
• Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis.
• Work directly with interdepartmental / intradepartmental stakeholders along with Molina Executives to establish/deliver/explain the business requirement as well as data/data points and do necessary escalation as required.
• Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors.
• Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
• Act as a subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics and provide training as required. Stay current with industry regulation changes and educate the team and management as necessary.
• Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytics reporting modules to ensure no impact to the end users.
• Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus.
• Develop training modules to help analysts understand processes, solutions or designs to meet the customer request for new/existing staff.
• Provide technical, functional and business training to other team members to enable them to perform the tasks required.
• Maintain a team culture to adopt fast faced agile environment and foster a positive attitude to take on challenging and time sensitive projects.
• Take accountability of tasks and projects assigned.

Job Qualifications

Required Education

Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline.

Required Experience

• 6 Years of experience in working with data mapping, scrubbing, scrapping, and cleaning of data.
• 5 Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design
• 5 years of experience in working with Microsoft T-SQL, SSIS and SSRS.
• Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage.
• 5 Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP.
• 5 Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting.
• 5 Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics.
• 5 Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions

PHYSICAL DEMANDS

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Info

Job Identification: 2035496

Job Category: Quality and Risk Adjustment

Posting Date: 2026-01-02T16:54:36 00:00

Job Schedule: Full time