Senior Risk Adjustment Analyst (Medicare)

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, andanticipatedcontributions to meet the needs of the business, along with internal pay equity and externalmarket-drivenrates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may bemodifiedin the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, andit’swhy our employees consistently vote us one of the “Best Places to Work in PA.”This position partners with the Risk Adjustment leadership team to support risk revenue management initiatives for Medicare and ACA programs. This role contributes to the strategic development and execution of risk adjustment, submission, analytics, and program management activities, with a focus on improving quality of care, optimizing revenue, strengthening analytical capabilities, and ensuring ethical, compliant, and audit-ready practices.Analyze large datasets to identify trends, patterns, and insights related to coding output, with a focus on improving quality.Take ownership of complex data workflows by building and maintaining scalable analytics pipelines using data tools such as SQL, SAS, and Snowflake.Leverage technical expertise to streamline recurring and/or ad-hoc analyses into reusable, scalable data products.Collect, interpret, and aggregate data from multiple sources to support risk adjustment, medical record coding, government audits, and quality initiatives.This position supports the development of risk-related policies, procedures, and governance strategies, identifies opportunities to improve processes and efficiency, and delivers actionable insights through enterprise reporting and analytics tools such as SQL, SAS, Snowflake, and Power BI.Knowledge:Deep understanding of and experience in Risk Adjustment (MA & ACA) business analytics with knowledge of different risk models including HCC, RxHCC, HHS-HCC and CDPS,Knowledge of Healthcare Plan systems, applications, databases and their underlying data structures, including but not limited to claims, eligibility and provider.Prefer foundational knowledge of predictive modeling and statistical analysis techniques.Experience:5 years' experience in data analysis, database technologies (Snowflake, SAS), SQL queries, etc.Experience analyzing risk adjustment data for trends, disease/diagnosis prevalence and condition hierarchy.Prefer experience with advanced analytics tools and programming languages, such as Python.Experience designing, building, and maintaining databases or analytical data structures.Skills:Experience creating detailed reports and communicate complex data structures.Possess high level of interpersonal skills.Strong problem-solving skills with the ability to think critically and provide data driven solutions.Ability to adapt to changing priorities of multiple customers.Advanced proficiency with SQL query techniques and exposure to business intelligence tools with advanced proficiency in SAS, Power BI, and Snowflake.Advanced skills in Microsoft Excel.Education and Certifications:Bachelor's Degree in Analytics, Information Systems, or related field or 9 years of relevant experience in lieu of degree.Physical Demands:While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.The employee must be able to work over 40 hours per week.employee must occasionally lift and/or move up to 5 pounds.We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Created: 2026-02-06