Senior Manager, Medicare Risk Adjustment Analytics

Job Overview

Key Responsibilities

• Lead strategic planning and management of risk adjustment accuracy and revenue optimization.
• Develop and maintain reports analyzing revenue financials and quantifying the impact of initiatives on Medical Loss Ratio (MLR).
• Write SQL queries to extract, manipulate, and analyze clinical operations, medical claims, and encounter data from data warehouses.
• Ensure all reporting and analytics comply with evolving CMS regulations and policies.
• Collaborate with clinical, financial, operational, legal, compliance, and IT teams to enhance risk adjustment precision and data integrity.
• Serve as a subject matter expert on CMS risk adjustment and maintain up-to-date knowledge of HCC models, regulations, and industry developments.
• Mentor and manage direct reports to build team capability and support professional development.
• Present analytical findings and business recommendations to senior leadership.
• Actively contribute to process improvement and operational excellence initiatives.

Required Experience

• Minimum 3 years of professional experience with healthcare data, particularly medical claims or encounter data using SQL.
• Minimum 3 years of experience in healthcare finance, consulting, medical economics, population health, or related analytics roles.
• At least 1 year of experience with creation, implementation, and measurement of prospective and retrospective risk adjustment programs (CMS RAPS/Encounter submissions).
• Proven experience managing and developing direct reports.

Technical and Functional Skills

• Expert knowledge of CMS-HCC models V24 and V28.
• Strong understanding of the claims data lifecycle, submission systems, and CMS regulations and audits related to risk adjustment.
• Solid grounding in healthcare economics, value-based care, and population health.
• Proficiency in SQL and analytics-driven reporting for strategic decision-making.

Leadership and Behavioral Traits

• Strategic thinker with intellectual curiosity and problem-solving capability.
• Strong communicator able to translate complex analytics into clear executive insights.
• Skilled in managing cross-functional partnerships and collaborating at all organizational levels.
• Hightly adaptable and comfortable navigating change and ambiguity.
• Entrepreneurial and self-motivated with a focus on continuous improvement.

Education

Bachelor's degree required; Master's degree preferred.