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Fallon Health Risk Adjustment Analyst - Remote Opportunity in Worcester, Massachusetts


About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Brief Summary of Purpose:

The primary role of the Risk Adjustment Analyst (RAA) will be to function as the Claims SME for the Risk Adjustment & Analytics Department. The RAA implements data analytic reports, as well as analyzes and researches data errors and issues, collaborating with internal departments to work toward error resolution and risk outcome improvement. The RAA will own the claims adjustment workflow associated with regulatory retrospective chart review efforts.

The RAA will have shared ownership within the Analytics staff for product line(s) as assigned by the Risk Adjustment Operations and Analytics Manager and will be a SME for the risk adjustment model(s) and related data submission requirements. This role will be familiar with all revenue streams relevant to the product line(s) and will develop reporting to enhance understanding of Fallon’s risk scores over time and to improve revenue accuracy. The RAA will review and apply all related regulatory requirements to department activities, i.e. audits, changes in rate models, changes in submissions, etc.

The RAA will be responsible for the monitoring and management of the end to end data follow of data submissions to vendors and government agencies to mitigate data leakage.

The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed.


  • Claims SME for assigned population

  • Analyze, prioritize & support resolution of Claims/ Encounter data errors

  • Work with the Senior Risk Adjustment Analyst on monthly operational and performance reporting

  • Monitor and manage end-to-end data submissions to vendors and government agencies for assigned populations to mitigate data leakage and/or submission errors.

  • Consolidate and distribute CMS and other government agency file to internal and external stakeholders

  • Update Medicare Dashboard with EDS submission results and documenting a summary of any issues encountered



BA or BS – Mathematics, Finance, Economics, Management, other


  • Intermediate to Advanced skill level with Microsoft SQL, Ms Excel, Access, Power point.

  • Basic Data Warehouse knowledge

  • Understanding of medical terminology and familiarity with medical records

  • Strong communication and strong written skills

  • Working knowledge of the provider-based healthcare industry and Risk Adjustment strongly preferred

  • Experience with Altyerx and SAS is plus.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Location US-MA-Worcester

Posted Date 3 weeks ago (11/11/2020 6:27 PM)

Job ID 6142

# Positions 1

Category Risk Adjustment