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Fallon Health Senior Risk Adjustment Analyst - Invest in your Future @ Fallonhealth! Remote Position! 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 Sr. Risk Adjustment Analyst will be to function as the Claims SME for the Risk Adjustment & Analytics Department. The Sr. RAAimplements 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 Sr. RAA will own the claims adjustment workflow associated with regulatory retrospective chart review efforts.

The Sr. Risk Adjustment Analyst will have shared ownership within the Analytics staff for product line(s) as assigned by the Sr. Director, and will be a SME for the respective 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 Sr. RAA will review and apply all related regulatory requirements to department activities, i.e. audits, changes in rate models, changes in submissions, etc. The Sr. RAA will also work with the Government Programs Actuary, product line management, Medical Economics and Care Services to provide analysis and recommendations to improve product performance.

The Sr. RAA will support development and implementation of targeted member listings for chart reviews, in home assessments and outreach efforts across Fallon’s product lines. The Sr. RAA will run commercial and other risk adjustment models and will work with IT to provide accurate data to external consultants for statewide commercial risk adjustment simulations. The Sr. RAA will also manage the Medicare PDE and DIR processes and review invoices for external vendors.

The Sr. Risk Adjustment Analyst will interface with external and internal customers and vendors to identify and/or analyze business problems and develop solutions, as well as improve workflows and business processes to optimize Risk Adjustment results.

The Sr. RAA will represent the Risk Adjustment & Analytics team, participating in corporate project workgroups and team initiatives as assigned. The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed.


Optimize risk adjustment data submissions

  • Claims SME for assigned population

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

  • Support targeting and selection of optimal populations for chart review and in home assessments

  • Coordinate accurate delivery of chart review findings for claims adjustment process

  • Support/enhance risk score monthly reporting

Product Line support

  • Educate product line management on drivers of variances from budget for all revenue streams

  • Meet regularly with product line management to identify and implement reports to improve product performance and identify opportunities to enhance revenue

Commercial risk adjustment support

  • Support accurate and timely data submission to CMS EDGE server

  • Develop targeted member lists for outreach efforts

  • Provide member level risk score data to support production of risk-adjusted P&L reporting

  • Act as liaison with external consultant for risk adjustment simulations

Manage PDE and other processes

  • Handle PDE response files and work with PBM on PDE error resolution

  • Provide updates for regulatory reporting dashboards

  • Manage review of invoices for external risk adjustment vendors

Corporate Project support

  • Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as required .



  • BA or BS – Business Administration, Finance, Economics, Healthcare Administration, other


  • Experience working in Medicare, Medicaid and/or Merged Markets support role: Risk Adjustment, Regulatory, Enrollment, Internal Audit, Accounting, Underwriting, Marketing, Claims – other

  • 5 years – Managed Care/Provider setting

  • Proficient/Advanced in Excel

  • 3-5 years-Excel

  • Ability to create presentations & exhibits in formats that meet various audience levels

  • SQL- Navigator and/or SAS experience

  • 2 years – SQL/SAS Experience

  • QNXT experience a 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 1 month ago (9/20/2021 4:55 PM)

Job ID 6511

# Positions 1

Category Finance