Work From Home Risk Adjustment Auditor Jobs in Nottingham, MD

Resp & Qualifications

PURPOSE: 
The purpose of a Sr. Data Analyst is to support the Health Services Risk Adjustment team through advanced analytics, reporting, and data-driven insights that enhance program performance and operational effectiveness. This position is responsible for developing and maintaining trusted data assets, producing meaningful analyses and reporting, and partnering with clinical, operational, financial, and technology teams to support Risk Adjustment initiatives across the organization.

Key responsibilities include analyzing program performance, monitoring key performance indicators, supporting risk score forecasting, developing member and provider targeting methodologies, creating and maintaining dashboards and reporting solutions, performing CMS, HHS, and MDH data reconciliations, and conducting ad hoc analyses to identify opportunities for improvement. The Senior Data Analyst will translate complex data into actionable insights while adhering to established data governance, compliance, and quality standards.

The ideal candidate will possess strong analytical and problem-solving skills, experience working with large healthcare datasets, and a solid understanding of Medicare Advantage, ACA, and Medicaid risk adjustment methodologies.

We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.
ESSENTIAL FUNCTIONS:

• Perform advanced data exploration, analysis, and solution development using programming languages and analytical tools to support Risk Adjustment initiatives. Leverage expertise across complex healthcare data structures including claims, encounters, provider, member, and risk adjustment data sources to identify trends, coding opportunities, and program improvement strategies.
• Collect, analyze, and interpret Risk Adjustment data to generate actionable insights and recommendations that improve risk score accuracy, program performance, financial outcomes, and regulatory compliance.
• Research, validate, and analyze data flow across operational and analytical ecosystems to ensure the integrity, completeness, and traceability of Risk Adjustment data used for reporting, forecasting, reconciliations, and regulatory submissions.
• Serve as a subject matter resource for Risk Adjustment analytics, supporting stakeholders with data inquiries, business questions, and issue resolution related to risk scores, coding initiatives, program performance, and regulatory reporting.
• Lead the design, development, testing, validation, and delivery of analytical solutions, dashboards, and reporting that support Risk Adjustment strategy, targeting initiatives, operational decision-making, and program effectiveness measurement.
• Partner with business and technical stakeholders to gather requirements and deliver data-driven solutions supporting Medicare, Medicaid, and ACA Risk Adjustment programs. Develop and maintain technical documentation, business requirements, data specifications, and process documentation consistent with organizational standards.

SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Data Science, Mathematics, Computer Science, Statistics, Business or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 5 years experience in an analytical/quantitative role.
Preferred Qualifications:

• Experience in Healthcare Industry
• Hands-on experience with Big Data/NoSQL Platforms with experience delivering production projects at scale. 
• Proficiency with SQL, Power Bi, Fabric, Python, and/or SSMS.

Knowledge, Skills and Abilities (KSAs)

• Quantitative, analytical and problem-solving skills.
• Knowledge and understanding of analytical tools, languages, applications, platforms.
• Excellent communication skills both written and verbal.
• Ability to learn quickly and take direction.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: 87,264 - 173,316

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

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.

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.

PHYSICAL DEMANDS:

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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