Consultant, Informatics Risk Adjustment

HealthPartners is hiring a Informatics Risk Adjustment Consultant. The Informatics Consultant -supports the Health Plan's risk adjustment operations by delivering trusted, prioritized, and compliant data insights that drive efficient workflows and improve risk score accuracy, while continuously refining processes through feedback. This role ensures the plan's risk adjustment outputs are accurately represented in claims and encounter data, analytics, and reporting.

The consultant serves as a bridge between the data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners. The role enables informed, compliant, and actionable risk adjustment program, while maintaining strong governance, audit readiness, and organizational standards.

ACCOUNTABILITIES:

Risk Adjustment Strategy & Program Execution

• Support planning and execution of annual risk adjustment initiatives (prospective, concurrent, and retrospective), aligned to plan goals and regulatory requirements.
• Translate risk adjustment priorities into practical workflows, playbooks, and measurable interventions across provider groups and vendor partners.
• Partner with risk adjustment operations to optimize data capture, risk score modeling, member stratifications, suspecting logic, and program outcomes.

Diagnosis Accuracy, Clinical Validity & Documentation Integrity

• Identify patterns of under-capture, over-capture, and potential diagnosis coding inaccuracies; drive suspecting logic and workflow improvements.
• Support provider-facing reporting

Encounter & Claims Data Quality (Core Health Plan Focus)

• Work with operational and technical teams to improve completeness, timeliness, and accuracy of encounter data and diagnosis submission (including resolving rejections, edit failures, and submission gaps).
• Define and monitor data quality KPIs (e.g., encounter internal validations, submission rates, acceptance rates, diagnosis completeness, provider group variation, lag time).

Provider & Vendor Enablement (External-Facing Consulting)

• Support relationships with provider groups, delegated entities, and vendor partners to improve data exchange and workflows
• Participate in vendor management activities (requirements gathering, performance monitoring, issue escalation, and continuous improvement).

Measurement, Analytics & Performance Reporting

• Define and track risk adjustment performance measures such as:
  
  
  
  • Reconfirmation rates and suspected-condition confirmation rates
  • Member visit rates and provider engagement
  • Condition prevalence shifts and variation analysis
  • Net risk score movement (where appropriate) with integrity guardrails, and drivers of risk
  • Encounter submission acceptance rates
  • Audit results and feedback loop reporting
  
  
• Partner with analytics teams to develop dashboards and actionable reporting (e.g., Power BI), and to ensure consistent measure definitions.

Compliance, Audit Readiness & Governance

• Partner with compliance, internal audit, and risk adjustment leadership to support audit readiness (e.g., documentation standards, monitoring, validation processes).
• Help implement controls and monitoring to identify outliers and reduce risk (e.g., unusual provider patterns, unsupported diagnoses, excessive suspecting false positives).
• Maintain familiarity with current risk adjustment policies and guidance, and support operational implementation of updates.

Cross-Functional Leadership & Change Management

• Facilitate collaboration between data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners.
• 
  

  When asked, co-lead small to medium initiatives end-to-end, including requirements definition, workflow design, stakeholder engagement, training, measurement, and sustainment.

  REQUIRED QUALIFICATIONS:

1. Education

• Bachelor's degree in health informatics, nursing, health information management, public health, business, or related field; or equivalent combination of education and experience.

2. Experience and Knowledge

• 5+ years of experience in health plan and/or risk adjustment-related domains, such as: risk adjustment operations, encounter data management, coding, clinical documentation integrity, provider performance, quality improvement, or healthcare analytics.
• Working knowledge of how diagnoses flow through EHR coding/chart review encounter/claims submission risk adjustment analytics.
• Experience collaborating with provider organizations and/or delegated entities to improve documentation and data submission practices.
• Experience using data to drive improvement: ability to interpret trends, variation, root cause issues, and performance metrics.
• Familiarity with Medicare Advantage (preferred) and/or other risk programs, including chart review concepts and audit sensitivity.

3. Skills

• Strong consulting, facilitation, and stakeholder management skills; able to influence without authority.
• Excellent written and verbal communication; able to create clear playbooks, training, and executive-ready summaries.
• Strong analytical thinking and operational problem-solving; comfortable navigating ambiguous issues across workflows and systems.
• High integrity and sound judgment; commitment to compliant, clinically appropriate documentation practices.
• Strong project management skills; ability to manage multiple workstreams, deadlines, and cross-functional dependencies.

PREFERRED QUALIFICATIONS:

• Credentials such as CRC, CPC, CCS, CDIP, CCDS (or comparable).
• Experience working directly with MA encounter submission processes, edit resolution, or encounter data ingestion/validation.
• Experience supporting chart retrieval/coding vendors and performance management (KPIs, SLAs, escalation paths).
• Familiarity with audit processes and documentation standards (e.g., retrospective validation, risk adjustment audits), and designing monitoring/controls.
• Experience developing or specifying requirements for dashboards and operational reporting (Power BI, Tableau, or equivalent).
• Solid working experience with SQL and relational database design
• Exposure to agile/scrum
• Experience using Azure suite of tools, Databricks, Azure Data Lake
• Experience in a highly regulated environment and comfort partnering closely with compliance and privacy.