Director Risk Adjustment Analytics at Blue Cross & Blue Shield of Rhode Island (Providence, RI)

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Under the general supervision of the Government Programs Leadership, the Director of Risk Adjustment Analytics shall provide analysis, data modeling, and business process support to the financial and clinical operations of the organization:

  • Subject matter expert in healthcare risk adjustment domain to analyze data and provide actionable insights
  • Familiarity in Healthcare Quality and analytics
  • Perform analysis and reporting activities relating to risk score calculation, claims/encounters data submission, chart review programs and audits, and related performance metrics
  • Design and build dashboards relating to risk adjustment and quality initiatives
  • Combine operational and financial acumen to support clinical performance management and financial management of population health programs by designing and supporting the implementation of standard reports and performing strategic analysis
  • Complete ad hoc analyses with concise results narratives for senior leadership, regional operations, and the field on both process and outcome metrics
  • Help to drive the performance management via innovative analytic insights in support of new and integrated service lines
  • Strategic thinking and analysis around financial and operational performance, opportunities for improvement


  • Provide reporting and analysis for risk adjustment activities
  • Develop advanced algorithms to perform analytics on large-scale and complex data for real-world health and healthcare applications using structured and un-structured data
  • Synthesize study results and translate into key findings, interpret results in the context of contract/market/industry dynamics, and communicate results to senior management and clients.
  • Independently develop high-quality deliverables in a timely manner
  • Present information using data visualization techniques
  • Propose solutions and strategies to address business challenges
  • Identify valuable data sources and automate collection processes.
  • Build collaboration among health stakeholders, working across organizations to bring consensus to achieve objectives. Become a sought-out subject matter expert by consistently producing high-quality analysis.
  • Conduct financial and trend analyses to improve processes
  • Analyze data utilizing statistical software like Python to evaluate data and discover data insights
  • Analyze risk scores and produce related reports, charts, and tables
  • Performing data mining of claims, encounters and RAPS/EDS data to identify trends, data issues and members with missing hierarchical condition categories (HCC's)
  • Working with clients/prospects, third-party partners, and the implementation team in supporting Risk Adjustment activities.
  • Performing high-level testing of new functionality from time to time
  • Assist implementation team with implementation and building of implementation services for RAF modules
  • Identify innovative ways to solve customer business problems using services and software
  • Complete significant projects that influence top-level decision making


Minimum Education and Experience:

  • Bachelor's degree in Computer Science, Information System or related discipline or equivalent work experience
  • 8+ years of data analytics experience and 3+ years of healthcare analytics experience
  • Strong understanding of Medicare Risk Adjustment Payment Model and Cycle including the knowledge base to calculate and manipulate risk scores

Preferred Education, Additional Qualifications and Experience:

  • Deep familiarity with CMS data and risk adjustment processes including MMR, MOR and EDS data
  • Strong understanding of Claims and Encounter data
  • Strong command on SQL Server (T-SQL), SSIS and SSRS, and Database design
  • Strong analytical/financial skills
  • Strong experience in dashboard and report development
  • Proficient with Microsoft Office, Access, and Visio
  • Proficient in Sisense, Power BI, Tableau, or other BI tools

Required Knowledge, Skills, and/or Abilities:

  • Large scale project experience as a key contributor.
  • Expertise in Process Review and Process Improvement
  • Advanced Knowledge of Medical Claims, Encounters, and Pharmacy Data
  • Excellent knowledge of Claims Code sets; CPT, HCPCS, HIPPS, LOINC, ICD-9, ICD-10
  • Excellent knowledge CMS transactions data and their elements as they pertain to CMS Medicare Risk Adjustment and adjudication
  • Deep understanding and knowledge on the HCC and RxHCC Risk Adjustment models
  • Strong verbal and written communication skills
  • Effective interpersonal skills, ability to effectively collaborate with others and work as part of a team
  • Excellent analytical and problem-solving skills

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit to view the "EEO is the Law" poster.

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More Information on Blue Cross & Blue Shield of Rhode Island
Blue Cross & Blue Shield of Rhode Island operates in the Healthtech industry. The company is located in Providence, RI. It has 828 total employees. It offers perks and benefits such as Flexible Spending Account (FSA), Dental Benefits, Vision Benefits, Health Insurance Benefits, Life Insurance and 401(K). To see all 8 open jobs at Blue Cross & Blue Shield of Rhode Island, click here.
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