Analyze Medicare Advantage and ACA risk adjustment data, CMS datasets, claims, encounters, eligibility, pharmacy, and medical record data. Develop SQL queries, reports, scorecards, dashboards, forecasts, and recommendations to improve risk adjustment performance, data quality, operational efficiency, and revenue. Partner with clients, executives, operations, technology, and analytics teams on solution development, process improvement, and strategic initiatives.
ABOUT ADVANTMED
Advantmed is a leading provider of risk adjustment, quality improvement, and value-based solutions to health plans and providers. We drive market leading performance with integrated technology, service, and program solutions that improve the risk adjustment and quality programs of our partners. Our solutions focus on identifying, managing, and documenting risk and quality performance, and the proactive clinical engagement of high acuity populations.
About the Role
- We are seeking a highly motivated and experienced Risk Adjustment Specialist to join our growing Data Analytics team. This role is ideal for a healthcare analytics professional with deep expertise in Medicare Advantage, ACA Risk Adjustment, CMS data, and healthcare analytics.
- The successful candidate will serve as a trusted subject matter expert, partnering with clients, operations, technology, and leadership teams to transform complex healthcare data into actionable insights that drive Risk Adjustment performance, improve operational efficiency, and support strategic decision-making.
Key Responsibilities
Risk Adjustment Analytics & Strategy
- Analyze Medicare Advantage and ACA Risk Adjustment program performance to identify opportunities for RAF improvement and revenue optimization.
- Provide expertise on CMS-HCC, RxHCC, Medicare Risk Adjustment methodologies, and industry best practices.
- Evaluate operational and financial performance metrics and develop data-driven recommendations.
- Support client-facing initiatives, business reviews, and executive presentations.
Healthcare Data Analysis
- Analyze, cleanse, transform, reconcile, and validate large healthcare datasets from multiple sources.
- Perform analysis across Claims, Encounters, Eligibility, Pharmacy, Medical Record Review (MRR), and Health Assessment datasets.
- Identify trends, anomalies, and opportunities through detailed data analysis.
- Conduct root cause analysis and recommend corrective actions to improve data integrity and operational performance.
CMS Data Management & Reporting
- Work extensively with CMS data sources, including MMR, MOR, and other Medicare Advantage datasets.
- Support Risk Adjustment reconciliation, forecasting, and financial impact analysis.
- Develop operational reports, scorecards, ad hoc analyses, and executive dashboards.
- Translate complex analytical findings into meaningful business recommendations.
Technical & Cross-Functional Collaboration
- Develop, optimize, and troubleshoot complex SQL queries, stored procedures, and data extraction processes.
- Debug existing reporting and analytical scripts.
- Collaborate with business, operations, technology, and analytics teams to implement scalable solutions.
- Support automation, process improvement, and operational excellence initiatives.
Requirements
Education
- Bachelor's degree in Healthcare, Statistics, Computer Science, Engineering, Business Analytics, or related field.
Experience
- 5+ years of healthcare data analytics experience, including data mining, mapping, transformation, validation, and reporting.
- 3+ years of hands-on experience in Medicare Advantage and/or ACA Risk Adjustment.
- 3+ years of experience as a Healthcare Data Analyst.
- 3+ years of advanced SQL development experience.
Healthcare & Risk Adjustment Expertise
Strong understanding of
- Medicare Advantage and ACA Risk Adjustment programs
- CMS-HCC and RxHCC models
- Medical Record Review (MRR) and Health Assessment processes
- Claims, Encounter, Eligibility, and Pharmacy data
- CMS data files, including MMR and MOR
- End-to-end Risk Adjustment lifecycle
- HEDIS and healthcare quality measures
Technical Skills
- Advanced SQL and Microsoft SQL Server
- SQL Server Management Studio (SSMS)
- Data mapping, reconciliation, and validation
- Root cause analysis and data quality management
- Ad hoc reporting and data extraction
Professional Skills
- Strong analytical and problem-solving abilities
- Excellent communication and presentation skills
- Experience working directly with clients and executive stakeholders
- Ability to independently manage multiple priorities in a fast-paced environment
Preferred Qualifications
- Experience supporting Medicare Advantage health plans, provider groups, or Risk Adjustment vendors.
- Experience with Power BI, Tableau, or other Business Intelligence platforms.
- Knowledge of Risk Adjustment financial forecasting and revenue analytics.
- Experience leading client solutioning discussions and strategic initiatives.
- Exposure to automation, process optimization, and operational excellence programs.
- Familiarity with FHIR, EMR/EHR integrations, and healthcare interoperability standards.
What You'll Bring
- Deep expertise in Risk Adjustment and healthcare analytics.
- Ability to convert complex healthcare data into actionable business insights.
- Strong client-facing and consultative skills.
- A continuous improvement mindset focused on operational excellence and innovation.
- The ability to work independently while collaborating effectively across teams.
Benefits
Why Join Us?
This is an opportunity to make a measurable impact on healthcare outcomes and financial performance by leveraging your expertise in Risk Adjustment, analytics, and strategic consulting. You will work alongside industry experts, solve complex business challenges, and help clients optimize their Risk Adjustment programs through data-driven decision-making.
If you are passionate about healthcare analytics, Risk Adjustment, and solving complex problems, we would love to hear from you.
Compensation for this role will be determined based on the selected candidate's experience and qualifications.
- Health Care Plan (Medical, Dental & Vision)
- Annual Performance Bonus
- Retirement Plan (401k, IRA)
- Life Insurance (Basic, Voluntary & AD&D)
- Paid Time Off (Vacation, Sick & Public Holidays)
- Family Leave (Maternity, Paternity)
- Short Term & Long Term Disability
- Work From Home
- Wellness Resources
Advantmed, LLC Santa Ana, California, USA Office
Santa Ana, CA, United States
Similar Jobs
Cloud • Security • Software • Cybersecurity • Automation
Drive enterprise sales growth across the Northeast by managing strategic accounts, generating pipeline, developing account plans, and leading complex B2B software sales cycles. Build C-level relationships, coordinate technical and customer success teams, guide customers through DevSecOps transformations, negotiate agreements, support implementation, forecast performance, and identify expansion opportunities. The role requires consultative selling, partner collaboration, market knowledge, and effective stakeholder communication within a remote team.
Top Skills:
DevsecopsGitlabSalesforce
Artificial Intelligence • Fintech • Insurance • Marketing Tech • Software • Analytics
Investigates, evaluates, reserves, negotiates, and resolves complex, high-exposure workers compensation claims. Determines coverage and compensability, manages litigation and settlement activities, identifies subrogation and Medicare Set Aside exposure, analyzes claims data, communicates with policyholders and counsel, and trains less experienced claims staff.
Top Skills:
ExcelMicrosoft Powerpoint
Artificial Intelligence • Fintech • Insurance • Marketing Tech • Software • Analytics
Manage complex commercial energy claims from initial notice through resolution, including coverage analysis, liability assessment, reserves, settlements, and litigation. Oversee defense counsel, experts, investigations, discovery, and multi-party catastrophic-loss matters. Collaborate with legal, underwriting, reinsurance, and technical teams; advise leadership on coverage and claims strategy; authorize payments and denials; mentor claims examiners; and support process-improvement initiatives.
What you need to know about the Los Angeles Tech Scene
Los Angeles is a global leader in entertainment, so it’s no surprise that many of the biggest players in streaming, digital media and game development call the city home. But the city boasts plenty of non-entertainment innovation as well, with tech companies spanning verticals like AI, fintech, e-commerce and biotech. With major universities like Caltech, UCLA, USC and the nearby UC Irvine, the city has a steady supply of top-flight tech and engineering talent — not counting the graduates flocking to Los Angeles from across the world to enjoy its beaches, culture and year-round temperate climate.
Key Facts About Los Angeles Tech
- Number of Tech Workers: 375,800; 5.5% of overall workforce (2024 CompTIA survey)
- Major Tech Employers: Snap, Netflix, SpaceX, Disney, Google
- Key Industries: Artificial intelligence, adtech, media, software, game development
- Funding Landscape: $11.6 billion in venture capital funding in 2024 (Pitchbook)
- Notable Investors: Strong Ventures, Fifth Wall, Upfront Ventures, Mucker Capital, Kittyhawk Ventures
- Research Centers and Universities: California Institute of Technology, UCLA, University of Southern California, UC Irvine, Pepperdine, California Institute for Immunology and Immunotherapy, Center for Quantum Science and Engineering
