CareFirst Careers

Sr Risk Adjustment Analyst (Medicare)

Resp & Qualifications

The Senior Risk Adjustment Analyst assumes a pro-active approach in ensuring the accuracy, completeness and timely submission of encounter data. Incumbent is responsible for performing complex analyses and problem resolution including data extraction, report design, report build and solution deployment to pre-determine failures in encounter data extracted from claims system as well as to determine resolutions for encounter rejections. Additional responsibilities include establishing and maintaining business process and technical workflow documents, collaborating with multiple stakeholders at various levels throughout the Company, as well as external entities, providing coordination and support as required.

Essential Functions:

  • Assists in designing an overall suite of analytic capabilities and actionable reports to solve problems, provide data-driven guidance, and monitor risk adjustment performance through encounter submissions. Provide analytical support on various strategies to ensure organizational goals are met and propose opportunities in maximizing reimbursement based on the CMS-HCC (Hierarchical Condition Code) model. Perform data mining of claims and data to identify trends, data issues and members with missing HCCs. Accurately monitor and reconcile submitted encounters against response files to ensure that submission gaps are being addressed in a timely manner. Interface with departments to improve and correct data.
  • Propose innovative approaches to create or improve automation and optimize data and analytic processes as well as reporting. Provide programming support to extract and analyze data from different enterprise systems. Develop, implement and maintain a provider and medical record collection database. Lead cross-functional and operational teams toward the goal of improved risk adjustment scores.
  • Understand state and federal encounter submission processes, CMS risk score methodology, including risk score calculation, financial risk receivable calculations, EDGE processes and key regulatory deadlines for data submission. Understand the impact of the HCCs on the risk adjustment revenue including interpretation of CMS guidelines, monitoring and determining the impact of any changes to the HCC model and supporting actuarial in the calculation risk adjustment revenue.
  • Support project management efforts including monitoring and evaluating progress against timelines, project milestones and key deliverables. Develop tracking and monitoring mechanisms for all Risk Adjustment and Coding programs. Support management in ensuring that key risk adjustment performance metrics and business objectives are defined and achieved.
  • Conduct analyses to develop a comprehensive understanding of a provider’s risk score trends, EMR systems and contracting arrangements to recommend and generate provider-specific engagement plans. Oversee the analysis and interpretation of provider-specific results and risk score trend information. Develop dashboard reporting and a regular schedule for delivering results of analyses to improve awareness and understanding of risk adjustment results and quality, accuracy and identification of member health conditions. Update, create and maintain business process and technical workflow documents.


  • Bachelors degree with 5 years experience with data analysis which includes use of statistical methods, experience with programming language
  • Experience with SAS, SQL, VBA or other programming language and MS Access Database
  • Experience with CMS risk score methodology, including risk score calculation and financial risk receivable calculations
  • Excellent analytical and problem-solving abilities.
  • High level statistical abilities.  The ability to work independently and with those in various departments and areas not directly reporting to the Division.
  • Ability to work with and support Senior Management and to disseminate and summarize information into a format that can facilitate high-level decision-making process



Department: MD Medicaid -ADMIN

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 6/20/21

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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