Technical Business Analyst Risk Adjustment (Healthcare)

Job Summary

We are seeking a Technical Business Analyst with experience in healthcare risk adjustment, data analytics, and healthcare information systems. The role will bridge business, clinical/coding, data, and technology teams to ensure accurate processing of risk-adjustment data and compliance with healthcare regulations.

Key Responsibilities

• Gather, analyze, and document business and technical requirements for risk adjustment applications and data processes.
• Work with healthcare, coding, clinical, actuarial, and technology teams to understand risk-adjustment workflows.
• Analyze member, claims, encounter, diagnosis, provider, and supplemental data used in risk-adjustment processes.
• Translate business requirements into functional and technical specifications, user stories, process flows, and acceptance criteria.
• Perform data analysis and validation using SQL to identify data quality issues, missing records, duplicates, and discrepancies.
• Support HCC (Hierarchical Condition Category)-based risk-adjustment processes and understand diagnosis-code-to-HCC mappings.
• Analyze ICD-10-CM, CPT/HCPCS, claims, encounter, and provider data relevant to risk adjustment.
• Work with data engineers and developers on ETL/data pipelines, APIs, databases, and healthcare data integrations.
• Perform source-to-target mapping, data profiling, reconciliation, and root-cause analysis.
• Create test scenarios and support SIT, UAT, regression testing, and defect resolution.
• Validate risk-adjustment outputs against business rules and regulatory requirements.
• Investigate discrepancies between claims/encounter data, coding results, and downstream risk-adjustment outputs.
• Participate in audits and support documentation required for regulatory and compliance activities.
• Communicate findings and requirements to both technical and non-technical stakeholders.
• Familiarity with healthcare data standards such as HL7, FHIR, X12/EDI, or healthcare data models is a plus.

Healthcare / Risk Adjustment Knowledge

• Understanding of Medicare Advantage (MA) and/or commercial risk adjustment.
• Knowledge of HCC models, risk scores, diagnosis codes, and risk-adjustment submissions.
• Familiarity with CMS risk-adjustment requirements and data submission concepts.
• Understanding of ICD-10-CM diagnosis codes and their relationship to risk adjustment.
• Knowledge of claims and encounter data, including professional, institutional, and pharmacy data, is desirable.

Business Analysis Skills

• Requirements elicitation and stakeholder interviews.
• Business process modeling and workflow documentation.
• User stories, functional requirements, and acceptance criteria.
• Data mapping and business-rule documentation.
• Gap analysis and impact analysis.
• Root-cause analysis.
• Agile/Scrum methodology.
• Cross-functional communication and stakeholder management.

Education & Experience

• Bachelor's degree in Computer Science, Information Technology, Healthcare, Business, or a related field.
• Typically 4 8 years of experience as a Business Analyst, Technical Business Analyst, Healthcare Business Analyst, or Data Analyst.
• Relevant experience in healthcare claims, risk adjustment, HCC, payer systems, or healthcare analytics is strongly preferred.
• Experience working with distributed/onsite-offshore technology teams is beneficial.