Risk Adjustment Developer

Position Summary:

Reporting to the Director of Encounter Data Management within the Revenue Cycle Department, the Risk Adjustment Data Developer is responsible for the design, development, and maintenance of data systems and tools that support Commonwealth Care Alliance's (CCA) risk adjustment and Hierarchical Condition Category (HCC) revenue programs. This position ensures the integrity, accuracy, and timeliness of data used for encounter submissions, risk scoring, and revenue optimization.

The Developer will work cross-functionally with analytics, IT, operations, and vendor teams to support and enhance data processing workflows related to CMS Encounter Data Processing System (EDPS) and Massachusetts Medicaid (Mass Health). Strong technical skills in SQL, data integration, and systems development are essential. Knowledge of Medicare risk adjustment methodologies is highly desirable.

The ideal candidate is a proactive and detail-oriented developer with strong problem-solving capabilities, capable of independently managing development tasks while collaborating in a team environment. This role may involve mentoring junior developers and supporting project leadership when needed.

Supervision Exercised:

• No, this position does not have direct reports.
  

Essential Duties & Responsibilities:

• Design, develop, and maintain automated data pipelines and systems to support risk adjustment and encounter data submissions (RAPS/EDPS).
• Implement and optimize SQL scripts, stored procedures, and ETL processes to ensure high-quality data processing.
• Collaborate with analysts and business users to define technical requirements and translate analytical needs into robust data solutions.
• Develop and support risk adjustment financial models that align with HCC revenue projections and CMS methodologies.
• Maintain and enhance reporting infrastructure to track data quality, submission errors, and risk score performance.
• Ensure timely and accurate flow of encounter and diagnosis data to external vendors and internal platforms.
• Conduct regular quality assurance checks to validate data integrity, implementing corrections and process improvements as needed.
• Create and maintain technical documentation of data workflows, business logic, and submission policies.
• Partner with IT, claims, and enrollment teams to improve systems integration and enhance the risk adjustment data ecosystem.
• Support audit readiness and regulatory compliance for Medicare and Medicaid risk adjustment programs.
• Represent the Risk Adjustment team in cross-functional initiatives as a technical subject matter expert.

Working Conditions:

• Standard office conditions.

Other:

• Standard office equipment

Required Education (must have):

• Bachelor's Degree in Computer Science, Information Technology, Health Informatics, or related technical field.

Desired Education (nice to have):

Required Licensing (must have):

• N/A

Required Experience (must have):

• 5+ years of experience in data development or engineering within a healthcare or managed care environment.

Desired Experience (nice to have):

Required Knowledge, Skills & Abilities (must have):

• Advanced proficiency in SQL and data transformation; experience troubleshooting and optimizing stored procedures.
• Experience building and maintaining ETL workflows and data integration processes.
• Strong understanding of healthcare data, including claims, encounters, diagnoses, and provider data.
• Familiarity with CMS risk adjustment methodologies and HCC coding preferred.
• Experience with data visualization tools such as Tableau, Looker, or Power BI is a plus.
• Excellent communication and collaboration skills; ability to work independently or in team settings.
• Prior experience working with EDPS data flows and Medicare Advantage programs is a strong advantage.

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):