Risk Adjustment Consulting Jobs (NOW HIRING)

Your Role

The Enterprise Retrospective Chart Review team oversees end to end retrospective coding operations, ensuring the accuracy, completeness, and compliance of medical record review across all risk adjusted lines of business. The team manages enterprise workflows, vendor performance, coding quality, audit readiness, and cross functional alignment with Clinical, Compliance, and Risk Adjustment partners.
 

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!  

Our Values: 

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. 
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. 

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Your Knowledge and Experience

• Requires a college degree or equivalent experience 
• Requires 3 years of prior relevant experience within healthcare, preferably Risk Adjustment
• Requires practical knowledge of Risk Adjustment obtained through professional experience and advanced education
• Requires familiarity with AI tools, including prompt engineering and workflow automation
• Requires experience building dashboards or visual reports that support operational decision making
• Requires strong communication skills for concise summaries and effective cross functional collaboration

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Your Work

In this role, you will:

• Analyze under the supervision of the core principles and functionality of decision and descriptive analytics including analyzing historical data, past performance and trends 
• Develop and run programs that apply to analytic decision techniques
• Contribute to successful programs for the team, engaged in typically one area related to vendor oversight, internal cross functional partnerships, tracking performance and measuring results
• Continuously learn about plan data including claim, premium, membership, and risk score assignment 
• Conduct data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
• Analyze operational performance to identify trends, risks, and improvement opportunities and to forecast retrieval volumes, coding workloads, and capacity needs using both traditional analytics and AIdriven modeling
• Design AIenabled workflows that enhance chart ingestion, data validation, and operational reporting for risk adjustment, using AI tools to improve efficiency and consistency
• Automate data processes by building Python and SQL solutions and applying AI applications to streamline vendor file processing, recurring reporting, and ad hoc analytics
• Produce operational reporting through dashboards and scorecards that summarize retrieval performance, coding outcomes, and risk adjustment trends, supported by AIassisted insight generation
• Manage data quality by ingesting weekly vendor data loads, performing QA checks, validating accuracy, and applying AI tools to support anomaly detection and data review