Informatics Risk Adjustment Consultant
Risk Adjustment Strategy & Program Execution
Support planning and execution of annual risk adjustment initiatives (prospective, concurrent, and retrospective), aligned to plan goals and regulatory requirements.
Translate risk adjustment priorities into practical workflows, playbooks, and measurable interventions across provider groups and vendor partners.
Diagnosis Accuracy, Clinical Validity & Documentation Integrity
Identify patterns of under-capture, over-capture, and potential diagnosis coding inaccuracies; drive suspecting logic and workflow improvements.
Support provider-facing reporting.
Encounter & Claims Data Quality (Core Health Plan Focus)
Work with operational and technical teams to improve completeness, timeliness, and accuracy of encounter data and diagnosis submission (including resolving rejections, edit failures, and submission gaps).
Define and monitor data quality KPIs (e.g., encounter internal validations, submission rates, acceptance rates, diagnosis completeness, provider group variation, lag time).
Provider & Vendor Enablement (External-Facing Consulting)
Support relationships with provider groups, delegated entities, and vendor partners to improve data exchange and workflows.
Participate in vendor management activities (requirements gathering, performance monitoring, issue escalation, and continuous improvement).
Measurement, Analytics & Performance Reporting
Define and track risk adjustment performance measures such as:
- Reconfirmation rates and suspected-condition confirmation rates
- Member visit rates and provider engagement
- Condition prevalence shifts and variation analysis
- Net risk score movement (where appropriate) with integrity guardrails, and drivers of risk
- Encounter submission acceptance rates
Audit results and feedback loop reporting.
Partner with analytics teams to develop dashboards and actionable reporting (e.g., Power BI), and to ensure consistent measure definitions.
Compliance, Audit Readiness & Governance
Partner with compliance, internal audit, and risk adjustment leadership to support audit readiness (e.g., documentation standards, monitoring, validation processes).
Help implement controls and monitoring to identify outliers and reduce risk (e.g., unusual provider patterns, unsupported diagnoses, excessive suspecting false positives).
Maintain familiarity with current risk adjustment policies and guidance, and support operational implementation of updates.
Cross-Functional Leadership & Change Management
Facilitate collaboration between data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners.
When asked, co-lead small to medium initiatives end-to-end, including requirements definition, workflow design, stakeholder engagement, training, measurement, and sustainment.