Commonwealth Care Alliance (CCA) needs to design, develop, and maintain data systems and tools to support its risk adjustment and Hierarchical Condition Category (HCC) revenue programs, ensuring the integrity, accuracy, and timeliness of data for encounter submissions, risk scoring, and revenue optimization.
Requirements
- Advanced proficiency in SQL and data transformation; experience troubleshooting and optimizing stored procedures.
- Experience building and maintaining ETL workflows and data integration processes.
- Strong understanding of healthcare data, including claims, encounters, diagnoses, and provider data.
- Familiarity with CMS risk adjustment methodologies and HCC coding preferred.
- Experience with data visualization tools such as Tableau, Looker, or Power BI is a plus.
- Prior experience working with EDPS data flows and Medicare Advantage programs is a strong advantage.
Responsibilities
- Design, develop, and maintain automated data pipelines and systems to support risk adjustment and encounter data submissions (RAPS/EDPS).
- Implement and optimize SQL scripts, stored procedures, and ETL processes to ensure high-quality data processing.
- Develop and support risk adjustment financial models that align with HCC revenue projections and CMS methodologies.
- Maintain and enhance reporting infrastructure to track data quality, submission errors, and risk score performance.
- Ensure timely and accurate flow of encounter and diagnosis data to external vendors and internal platforms.
- Conduct regular quality assurance checks to validate data integrity, implementing corrections and process improvements as needed.
- Partner with IT, claims, and enrollment teams to improve systems integration and enhance the risk adjustment data ecosystem.
Other
- 5+ years of experience in data development or engineering within a healthcare or managed care environment.
- Collaborate with analysts and business users to define technical requirements and translate analytical needs into robust data solutions.
- Create and maintain technical documentation of data workflows, business logic, and submission policies.
- Support audit readiness and regulatory compliance for Medicare and Medicaid risk adjustment programs.
- Represent the Risk Adjustment team in cross-functional initiatives as a technical subject matter expert.
