Sr. Business Analyst- Risk Adjustment

Dice is seeking an experienced Business Analyst to support strategic and operational initiatives for a health plan focused on government lines of business such as Medicaid and Medicare. The role involves collaborating with various teams to improve risk adjustment methodologies and regulatory compliance, while analyzing data to enhance performance and member outcomes.

Responsibilities:

• Elicit, analyze, and document business requirements for initiatives impacting government programs, including risk adjustment, care management, claims, and provider engagement
• Support risk adjustment programs, including data validation, gap identification, suspecting logic, and performance tracking
• Collaborate with clinical and coding teams to ensure accurate HCC capture and documentation improvement strategies
• Analyze large datasets (claims, encounters, clinical data) to identify trends, gaps, and opportunities for improved RAF scores and quality outcomes
• Develop and maintain business process flows, data mappings, and functional specifications
• Facilitate cross-functional workshops and stakeholder meetings to align on scope, priorities, and solutions
• Support regulatory compliance initiatives (CMS, state Medicaid agencies), including audit readiness (e.g., RADV)
• Perform UAT planning and execution, including test case development and defect tracking
• Create executive-ready summaries, dashboards, and reports to communicate key insights and program performance
• Identify process improvement opportunities and support automation, workflow optimization, and operational efficiency initiatives

Requirements:

• Bachelor's degree in Healthcare Administration, Business, Information Systems, or related field
• 5+ years of Business Analyst experience within a healthcare payer organization
• Direct experience supporting government programs (Medicaid, Medicare Advantage, Duals, ACA Exchange)
• Knowledge of risk adjustment models and processes (CMS-HCC, HHS-HCC)
• Experience working with claims, enrollment, provider, and clinical datasets
• Proficiency in requirements documentation (BRDs, FRDs, user stories) and process modeling
• Experience with data analysis tools (e.g., SQL, Excel, or BI tools such as Power BI/Tableau)
• Excellent communication skills with ability to interface with both business and technical stakeholders
• Experience with value-based care programs, quality initiatives (HEDIS, Star Ratings)
• Familiarity with coding guidelines (ICD-10, CPT) and clinical documentation improvement (CDI) practices
• Exposure to care management platforms, population health tools, or risk adjustment vendors
• Agile/Scrum experience and familiarity with tools such as Jira or Azure DevOps