The Role

The Senior Data Analyst is responsible for subject matter expertise in data analysis with emphasis on Medicare Risk Adjustment and Encounter processing, payment reconciliation as well as RAPS processing. The data analyst will be the lead technical resource on new RA implementations, new and existing customer RA consultation, and an escalation point for data issues.

Responsibilities include:

  • Provide analysis for decision support
  • Create core reporting dashboards summarizing and trending all aspects of Medicare business; CMS Revenue, Enrollment and Risk Adjustment
  • Create predictive models using SAS and SQL
  • Design and maintain a SQL Data Repository used for reporting and analytics, creating cross reference tables, restating CMS MMR data and program SQL logic for summary tables used for reporting providing oversight and working with management on resolution and decisions related to product development critical issues and conflicts
  • Use SSIS/Pervasive to create ETL processes for importing member, claims, encounters and pharmacy data (PDE) into SQL data repository
  • Perform data mining of claims, encounters and RAPS data to identify trends, data issues and members with missing hierarchical condition categories (HCC’s)
  • Perform audits on submitted claims and encounter data to verify CMS regulatory compliance
  • Perform cyclical RAPS data submission reconciliation to ensure maximum data throughput, comparing RAPS submission to claims and encounter data identifying claims and encounters that have not been submitted to CMS
  • Work with clients/prospects, third-party partners, other Product Managers, the Sales and Marketing team, and the Implementation team in designing integration solutions to meet their needs
  • Perform high-level testing of new functionality from time to time
  • Assist Implementation team with implementation and building of implementation services for RA modules
  • Identify innovative ways to identify and solve customer business problems using services and software

Skills & Requirements:

  • Large scale project experience as a key contributor
  • Expertise in process review and improvement
  • Advanced knowledge of medical claims, encounters, and pharmacy data
  • Excellent knowledge of claims code sets; CPT, HCPCS, LOINC, ICD-9, ICD-10
  • Deep understanding and knowledge on the HCC and RxHCC Risk Adjustment models
  • Data analysis and RA data model (5+ years)


  • Requires bachelor’s degree from an accredited institution or equivalent work experience
  • Excellent analytical and problem solving abilities (expert)
  • SQL, SAS, Excel and Access programming skills (advanced)
  • Querying large data sets across various platforms; SQL, Access, Oracle, DB2 and SAS Data Repositories (expert)
  • SQL 2005/2008 (R2) Expertise – SSIS, SSRS, ETL tools, Tables, Views, Stored Procedure, Performance Tuning and Queries (expert)
  • Medicare Risk Adjustment Payment Methodology and Data Knowledge; MMR, MOR, and TRR Files (advanced)
  • Great written and oral communications skills (advanced)
  • Organization and planning skills (expert)


  • Software development experience
  • Working with an off-shore development and QA team (India)

Location: Irvine, CA

If you feel you meet these requirements, please send your resume in Word or PDF format to