Senior Business Analyst Auditing/ Risk Adjustment & Compliance

Title: Senior Business Analyst Auditing/ Risk Adjustment & Compliance

Dept: SHS Risk Management
Will this position be required to work onsite for any reason at any time? If the candidate is within a reasonable distance from the Detroit or Grand Rapids location that is a possibility. If so, it would be one day per week. If not, then the position will be fully remote.

Engagement Description This engagement requires a highly skilled Risk Adjustment Business Analyst who can bridge regulatory requirements with operational execution across Medicare Advantage and other risk-bearing programs. The analyst will help ensure compliance with CMS guidelines, minimize audit risk, and contribute to accurate population health representation and financial performance.
The ideal candidate will bring a strong foundation in interpreting complex risk adjustment models (e.g., CMS-HCC, V28), gathering and translating business requirements, and using data analytics to identify gaps and opportunities. In addition to supporting vendor oversight, quality improvement efforts, and internal audit preparedness, the analyst will coordinate coding projects internally and with third-party coding platforms, evaluate the results, and package those outcomes for submission.
Success in this role demands cross-functional collaboration, critical thinking, and the ability to operate in a fast-paced, high-stakes environment. This engagement directly supports our organization's ability to remain compliant, optimize RAF accuracy, and achieve sustainable reimbursement outcomes.

Top 3 Required Skills/Experience
Business Requirements Gathering:
o They interpret complex risk adjustment programs, initiatives, data, and relevant regulations.
o They collaborate with stakeholders to gather and document business requirements for risk adjustment programs, translating them into functional specifications for technical teams.
Reporting and Analytics
o They develop and maintain reports to track key performance indicators (KPIs) related to risk adjustment coding and provide insights for decision-making.
o They utilize data analytics to identify potential data issues and proactively address them and assists with plans to implement effective compliance controls.
Process Improvement:
o They analyze existing processes, identify areas for improvement, and develop strategies to enhance operational efficiency and accuracy in risk adjustment processes.
o They manage quality audits and reviews of clinical documentation and coding practices to support accurate risk adjustment.
They assist with implementing and monitoring compliance controls, ensuring adherence to regulations and reducing the risk of non-compliance.

Required Skills/Experience The rest of the required skills/experience. Include:
Business Skills:
o Risk Adjustment Program Knowledge: Understanding of relevant risk adjustment programs, such as Medicare Advantage, and their specific compliance requirements.
o Business Process Analysis: Ability to analyze existing business processes, identify inefficiencies, and recommend improvements to enhance compliance and performance.
o Requirements Gathering and Documentation: Experience in gathering requirements from stakeholders, documenting business processes, and creating functional specifications for system enhancements.
o Problem-solving: Ability to identify and assist with resolving complex compliance issues related to risk adjustment data and processes.
o Communication: Excellent verbal and written communication skills to effectively communicate with internal teams, external partners, and regulatory bodies.
o Attention to Detail: Meticulous attention to detail to ensure accuracy and compliance in data and processes.
o Project Management: Ability to manage projects related to risk adjustment initiatives and compliance projects, requiring skills like defining scope, identifying resources, and scheduling.
o Stakeholder Management: Ability to collaborate effectively with various stakeholders, including clinical staff, IT teams, and management.
o Critical Thinking and Decision-Making: Ability to analyze situations, make informed decisions, and develop solutions to complex problems.
o Adaptability: Ability to adapt to changes in regulations and risk adjustment programs

Preferred Skills/Experience Optional but preferred skills/experience. Include:
SQL Databricks experience
Other relevant certifications: Depending on the specific role and focus, other certifications like the Certified Professional in Healthcare Information & Management Systems (CPHIMS), Certified Professional Medical Auditor (CPMA), or certifications related to specific risk adjustment models (e.g., Medicare Advantage) may also be preferred or beneficial.
CRC certified

Education/Certifications Include:
Bachelor's degree in healthcare administration, business, data science, or a related field with strong quantitative and analytical coursework