Risk Adjustment Analyst I/II/III/IV - 012600 at Univera Healthcare (Buffalo, NY)

| Buffalo, NY
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PLEASE NOTE: With limited exceptions, our company is requiring all employees to be vaccinated against COVID-19 by Jan. 1, 2022. We also currently mandate vaccinations for employees who enter our buildings. Please keep this in mind when applying for positions at our organization.


The Risk Adjustment Analyst performs data and analytical services in support of optimizing risk adjusted revenue, maintaining compliance with CMS and NYS standards and modeling financial impacts of changes in risk adjustment data and methodologies. This position interacts with analytical/coding staff in all regions, vendors, as well as internal departments such as Finance, Actuarial, Operations, Network Management, Provider Contracting, Legal, and Compliance. Upper levels of the role also interact with external agencies like BCBSA, AHIP, NYS DFS and CMS as well as outside consultants. Develops financial projections and conducts analysis for risk adjustment projects including retrospective chart review and prospective initiatives. The Risk Adjustment Analyst gathers, standardizes, and consolidates financial claims, membership and premium data into data sets that are used for risk adjustment analytical and reporting needs. Analyst should leverage industry resources to increase knowledge and improve ROI of risk adjustment activities.

Essential Responsibilities/Accountabilities:

Level I:
• Maintains current knowledge of risk adjustment models such as: CMS' Hierarchical Condition Categories (HCC) and RxHCCs, HHS HCCs and Clinical Risk Groups (CRGs) along with other open source and third-party models.
• Responsible for encounter data collection, processing, and reconciliation; including identification of trends.
• Supports pricing work through estimation of risk scores and associated revenue.
• Participates in regulatory/external party audits.
• Supports RADV analytics.
• Maintains SOX controls related to financial reporting of risk adjusted revenue.
• Calculates ROI for risk adjustment vendors, initiatives, and projects.
• Supports analysis of regulatory changes in determination of the Health Plan impact.
• Assists in the preparation of risk adjustment analyses.
• Supports higher level analysts on special projects involving other areas of the company.
• Assists in performing analyses used in the development of financial plans, re-forecasts, and other financial projections.
• Assists in efforts to continually improve data capabilities and quality of department analysis and reporting.
• Develops ad hoc reports to supplement risk adjustment processes through query building and data extraction.
• Highlights downstream impacts of data/system changes (ICD-10 transition, etc.).
• Assists in the development of risk scores in support of pricing and forecasting.
• Supports risk sharing analyses, capitation development, and associated settlements.
• Assists and/or supports other Risk Adjustment teams or Health Plan departments to complete projects or tasks as needed.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I essential responsibilities/accountabilities):
• Shares knowledge with newer department employees.
• Assists in the development of risk adjustment analyses concerning complex issues and trends, coordinates with staff.
• Works with outside vendors/auditors during implementation and maintenance of key projects.
• Identifies and develops corrective action with regards to Data Warehouse integrity issues.
• Reconciles Data Warehouse data with corporate financials.
• Initiates and leads efforts to continually improve data capabilities and quality of department analysis and reporting.
• Draws together facts and input from a variety of sources.
• Accountable for loading monthly data marts, updating hand-managed tables, and maintaining code that generates the information contained in those data marts and tables.
• Provides decision support in the form of advanced statistical analysis/business intelligence
• Performs advanced programming and statistical analysis/support for ad hoc requests.
• Proposes and assists in development of risk adjustment process improvements and automation of processes utilizing data integration software.
• Participates in on-going training for analytic and business intelligence tools.

Level III (in addition to Level II essential responsibilities/accountabilities):
• Develops risk scores for rate filings. Maintains methods and models or formulas for all lines of business.
• Develops risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff.
• Manages projects, including development of project plans, tracking and reporting the status of projects, coordination/leading of meetings and presentation of results to management.
• Provides effective technical advice and support to assist management in meeting corporate goals and identifying strategy. Involves other departmental areas as needed.
• Develops and reviews policies and procedures for risk score processing and error resolution.
• Facilitates and educates on existing processes for cross-training and business continuity purposes.
• Fosters an environment of continuous improvement. Constantly explores ways to increase efficiencies and productivity, reducing waste, and reducing costs.

Level IV (in addition to Level III essential responsibilities/accountabilities):
• Recommends departmental annual performance goals.
• Leads risk adjustment analyses concerning complex issues and trends, coordinating with several different disciplines and staff.
• Interprets how regulatory changes affect Health Plan and develops impact analyses.
• Provides support to assist management in meeting corporate goals and strategic decision making.
• Provides decision support and performs data mining functions to identify trends in the data.
• Interacts with Actuarial leadership to create predictive models using information obtained from mining or analysis.
• Proposes new SOX control designs to management as needed.

Minimum Qualifications:


We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels:
• Bachelor's degree in Math, Economics, Actuarial Science, Computer Science, general Sciences or allied field and a minimum of one year relevant experience required. In lieu of experience, actuarial exams, technical certifications or programming coursework are required.
• Exceptional analytical skills, with strong verbal and written communication skills.
• Strong organizational skills and ability to prioritize, multitask, and work in fast pace environment.
• A strong understanding of health insurance & health insurance products, managed care, accounting principles, the competitive market, the legislative environment, and any regulatory issue affecting the Health Plan is expected to be acquired.
• Focused on meeting the expectations and requirements of both internal and external customers.
• Self-motivation, initiative, and an ability to perform under pressure with little supervision.
• Strong PC skills including Microsoft Office Suite, (Excel, Access, Word, PowerPoint, Outlook, Teams) and familiarity with data integration tools, such as SAS, SPSS, R, Power BI, Tableau, etc., required.
• Experience with programming languages such as base SAS, SQL, R, Python, C, C++, C#, Java, or similar languages, preferred.
• Desire to participate in the Actuarial Study Program, pursue SAS Certification or related career path preferred.
• Understanding of basic principles and design of data warehousing.
• Familiarity with medical claims and medical terminology preferred.

Level II (in addition to Level I minimum qualifications):
• Three years actuarial or related industry experience required OR

o Two years actuarial or related industry experience and two actuarial exams is required.
• 1 year of experience with data integration tools and/or programming languages. SAS Base Certification preferred.
• Highly proficient computer skills including Excel, Word, SAS, Cognos, PowerPoint and intermediate SAS or equivalent programming language proficiency.
• High level understanding of non-Actuarial functions such as Rating, Underwriting, Accounting, Provider Contracting, Network Management, Product Development, Medical Management, etc., and how they impact Health Plan operations and financials.
• Knowledge and understanding of HHS-HCC, CMS-HCC or CRG Risk Adjustment Models

Level III (in addition to Level II minimum qualifications):
• Six years Risk Adjustment or related industry experience required OR

o Three years actuarial or related industry experience and four actuarial exams or SAS Certification I.
• Strong ability to recognize and automate repetitive tasks.
• Ability to perform complex modeling independently.
• Advanced SAS programming or equivalent programming proficiency and experience with data integration & Business Intelligence tools preferred.
• Project Management/Process Improvement knowledge preferred.

Level IV (in addition to Level III minimum qualifications):
• Ten years Risk Adjustment or related industry experience required OR

o Four years actuarial or related industry experience in conjunction with ASA & MAAA credentials or SAS expertise and experience with data mining and forecasting.
• A strong understanding of non- Risk Adjustment functions such as Actuarial, Care Management, Accounting, Provider Contracting, Network Management, Product Development, etc., and how they impact Health Plan operations and financials.

Physical Requirements:

  • Works from a desk most of the time.

The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.


Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
More Information on Univera Healthcare
Univera Healthcare operates in the Healthtech industry. The company is located in Buffalo, NY. Univera Healthcare was founded in 2022. It has 337 total employees. To see all 36 open jobs at Univera Healthcare, click here.
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