Healthcare Payer Business Analyst - Government Programs/Risk Adjustment

Business Analyst (Healthcare Payer Government Programs/Risk Adjustment)

Tentative duration - 06 Months with Possible extension

REMOTE (EST candidates strongly preferred)

Position Summary

We are seeking an experienced Business Analyst to support strategic and operational initiatives for a health plan focused on government lines of business (Medicaid, Medicare, and ACA Exchange). This role will partner closely with clinical, operational, compliance, and technology teams to drive initiatives related to risk adjustment, regulatory reporting, and value-based care programs.

The ideal candidate brings strong healthcare payer experience, an understanding of risk adjustment methodologies (HCC, RADV, RAPS, EDS), and the ability to translate complex business requirements into actionable solutions that improve performance, compliance, and member outcomes.

Key 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

Required Qualifications

• 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

Preferred Qualifications

• 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

Key Competencies

• Strong analytical and problem-solving skills
• Deep understanding of healthcare payer operations and regulatory environment
• Ability to translate business needs into technical requirements
• Detail-oriented with strong focus on data accuracy and compliance
• Collaborative mindset with strong stakeholder management skills