Business Analyst, Risk Adjustment

Come join our team! Help us tackle the data usability challenge for payers. Your expertise and experience will help drive meaningful performance outcomes. You'll also have the chance to advance your career, acquire new skills, and collaborate with some of the most innovative minds in payer data management. 

We are seeking an experienced Business Analyst with strong Risk Adjustment, Value-based care, or population health subject matter expertise to join our growing team. You will act as a liaison between business stakeholders, the data modeling team, and technical teams, ensuring client needs and business requirements are translated into actionable technical specifications resulting in seamless data exchange and efficient data integration between formats and systems. You will contribute expertise and experience supporting payer needs across the risk adjustment continuum or with value-based care or with population health, etc. Additionally, your demonstrated hands-on experience with CMS files, business requirements gathering, and data analysis will help optimize client implementation and solve for some of payers’ most pressing business challenges. 

You Will Be Responsible for: 

• Requirements Gathering and Analysis. Define, analyze, and document detailed functional and technical requirements for specific data solutions. Tasks may include collecting requirements from internal SMEs, partnering closely with Client Delivery and/or Customers to gather and refine technical and business requirements, developing and reviewing QA/user acceptance testing criteria, and business systems analysis, including data and gap analyses. 
  
  
• Stakeholder coordination/collaboration: Be a knowledgeable bridge between clients, product management, data modeling, SMEs, and other team members to define, document and share detailed functional and technical requirements and expected impact using all of the tool in your technical BA toolkit. 
  
  
• Mock-ups/Prototyping: Create mocks-ups, sample reports, and/or output tables to help visualize and communicate requirements, workflows, and expected results, based on client problems to be solved, business rules, and technical requirements.  
  
  
• User Acceptance Testing/QA Process. Collaborate with key stakeholders to define user stories, test cases, QA/User acceptance testing criteria for data solutions.   
  
  
• Partnering with Agile Scrum Teams: Participate in relevant agile ceremonies, build user stories according to requirements, and help define test cases and acceptance criteria.  
  
  
• Solution Maintenance. Co-own maintenance and create of artifacts that includes but is not limited to document portal/repository, workflows/diagrams, data mapping and technical requirements documents, analytics/business logic, user stories, and UAT scenarios and test cases. 
  
  
• Continual Learning. Keep up to date on latest industry trends in how payers are using data to drive improvement in outcomes. Leverage this expertise to continue to refine how solutions are developed and refined to maximize value for clients.  
  

Requirements

• Strong analytical and problem-solving skills with the ability to interpret healthcare data and draw actionable insights. 
  
• 3+ years of expertise/experience in Risk Adjustment - Medicare Advantage risk adjustment, Medicaid risk adjustment, or Affordable Care Act (ACA), CMS-HCC, HHS-HCC, and state-specific Medicaid models (e.g. CDPS, 3M CRG), including deep understanding of hierarchical condition categories is preferred. 
  
• 3+ years of hands-on experience with risk adjustment files and data types related to various risk adjustment reports 
  
• Monthly Membership Report (MMR), Medicare Operations Report (MOR), MAO-004, MAO-002 
  
• RAPS Returns, EDPS reports, Plan payment reports 
  
• 3+ years hands-on experience with US healthcare data (claims, clinical, encounter, member, provider, CMS files, 837s etc.) and standards (e.g., HL7, FHIR, EDI, CDA) 
  
• Proficiency in data mapping and data exchange protocols (e.g., API, JSON, XML) related to health information systems. 
  
• 5+ years of progressive experience in business requirements management (definition, documentation, mock-ups, data analysis) 
  
• 3+ years experience participating in UAT process management – test case planning and scenarios, writing UAT acceptance criteria, UAT test case execution, tracking and resolving defects, and UAT closure 
  
• Proficiency with data analysis and data visualization tools (e.g. Excel, SAS, PowerBI,Tableau, etc.) 
  
• Strong communicator who can share domain expertise effectively across multiple departments from Sales, Client Delivery, Product, Engineering, and Information Security 
  
• Excellent organizational skills with the ability to manage multiple projects and timelines. 
  
• Strong attention to detail and commitment to data integrity and compliance. 
  
• "Roll up your sleeves mentality" working side-by-side with your team. 
  
• Self-starter with demonstrated ability to drive workstreams independently and manage risks with strong compass on when to escalate issues.
  
• Demonstrated ability to thrive in a fast-paced, dynamic startup environment.
  

Nice-to-Have Qualifications: 

• Working knowledge of health insurance markets, government sponsored health plans (Medicare/Medicaid), value-based care arrangements, quality management and population health programs; payer systems, and regulatory compliance 
  
• Experience with EHRs and/or HIEs and healthcare data workflows.
  
• Familiarity with cloud platforms (e.g., AWS, Azure, Databricks, Snowflake, etc.) for hosting healthcare applications and data storage.
  
• Proficiency with programming languages (e.g. Sql, Python) .
  
• Interest in Advanced Analytics, Data Science, and/or GenAi