Full-Time
Risk Adjustment Consultant
Blue Shield of California
5,001-10,000 employees
California nonprofit health insurance provider
Compensation Overview
$37.35 - $63.16/hr
California, USA + 1 more
More locations: Oakland, CA, USA
Hybrid
Most teams require two in-office days each week; employees more than 50 miles from an office will determine in-office time based on business need.
Bachelor's
 Medical, Clinical & Veterinary (1) |
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- A college degree or equivalent experience is required.
- Three years of relevant experience within healthcare is required, preferably in risk adjustment.
- Practical knowledge of risk adjustment obtained through professional experience and advanced education is required.
- Familiarity with artificial intelligence tools, including prompt engineering and workflow automation, is required.
- Experience building dashboards or visual reports that support operational decision-making is required.
- Strong communication skills for concise summaries and effective cross-functional collaboration are required.
- Analyze historical data, past performance, and trends using decision and descriptive analytics principles and functionality under supervision.
- Develop and run programs that apply analytic decision techniques.
- Contribute to programs involving vendor oversight, internal cross-functional partnerships, performance tracking, and results measurement.
- Learn about plan data, including claims, premiums, membership, and risk score assignments.
- Conduct data analysis, document and verify assumptions used in member risk data and score submissions, and establish revenue accruals.
- Analyze operational performance to identify trends, risks, and improvement opportunities, and forecast retrieval volumes, coding workloads, and capacity needs using traditional analytics and artificial-intelligence-driven modeling.
- Design artificial-intelligence-enabled workflows to enhance chart ingestion, data validation, and operational reporting for risk adjustment.
- Automate data processes by building Python and SQL solutions and applying artificial intelligence applications to streamline vendor file processing, recurring reporting, and ad hoc analytics.
- Produce operational reporting through dashboards and scorecards summarizing retrieval performance, coding outcomes, and risk adjustment trends, supported by artificial-intelligence-assisted insight generation.
- Manage data quality by ingesting weekly vendor data loads, performing quality-assurance checks, validating accuracy, and applying artificial intelligence tools to support anomaly detection and data review.
- Risk adjustment experience within healthcare is preferred.
Blue Shield of California is a nonprofit health plan provider that offers medical insurance options for individuals, families, and employers within California. It operates as a mutual benefit corporation and maintains a broad network of healthcare professionals and facilities, enabling members to access care and manage claims through an online portal. Its services include preventive care programs and digital health coaching, with prior authorization required for certain medical, surgical, and some prescription drugs to control costs and ensure medical necessity. The company draws a substantial portion of its membership from CalPERS and focuses on delivering stable, affordable access to care within the state. Its goal is to provide members with reliable health coverage, a wide provider network, and tools to manage their health and expenses efficiently.
Company Size
5,001-10,000
Company Stage
N/A
Total Funding
N/A
Headquarters
null
Founded
1939
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Simplify's Take
What believers are saying
- July 31, 2026 Providence renewal preserved access for Commercial HMO, PPO, and Medi-Cal members.
- August 2026 Cedars-Sinai deal secured Southern California access across hospitals, surgery centers, and physicians.
- 2026 individual-plan premiums rose 9.3%, supporting revenue after 2024 premium revenue reached $27.1 billion.
What critics are saying
- The November 2025 ghost-network lawsuit targets Blue Shield, Magellan, and network accuracy.
- Community Medical Centers stayed out-of-network from February 1, 2026, exposing members to disruption.
- California regulators can force rate, network, or contract concessions that erode margins and membership.
What makes Blue Shield of California unique
- California-only nonprofit with nearly 6 million members and $28 billion revenue.
- Long-term provider contracting with Cedars-Sinai, Providence, and Community Health System anchors network depth.
- Board adds Kedar Mate, signaling tighter focus on healthcare quality and AI deployment.
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Benefits
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Company News
Blue Shield of California and Cedars-Sinai Health System extend long-term partnership into the next decade. New Agreement Ensures Continued Access to Cedars-Sinai's Nationally Recognized Care, While Advancing Shared Goals for Quality, Patient Experience and Affordability Strategic partnership between Blue Shield of California and Cedars-Sinai Health System. Blue Shield of California and Cedars-Sinai Health System have reached a new long-term agreement that ensures the nonprofit health plan's Commercial HMO and PPO members will continue to have in-network access to Cedars-Sinai Health System facilities and providers throughout Southern California. The four-year agreement builds on a longstanding relationship that has connected Blue Shield members with Cedars-Sinai Health System's nationally recognized care and establishes a framework for continued collaboration in the decade ahead, focused on quality, improved outcomes, and affordability. The renewed collaboration includes Cedars-Sinai Medical Center, Cedars-Sinai Marina Hospital, Torrance Memorial Medical Center, Huntington Hospital, affiliated ambulatory surgery centers and ancillary providers, as well as providers participating in the Cedars-Sinai, Torrance Memorial, and Huntington Health physician networks. Together, Blue Shield and Cedars-Sinai Health System remain committed to delivering access to care, exceptional member experience, and greater value for Californians. "As a nonprofit health plan, we work closely with leading providers like Cedars-Sinai Health System to modernize the healthcare system while enhancing patient outcomes," said Mike Stuart, president and CEO of Blue Shield of California. "Cedars-Sinai Health System recognizes the importance of a coordinated approach to supporting the health of our members. We are pleased they will remain in our network and look forward to advancing strategic initiatives." "Our commitment to Los Angeles is rooted in providing the highest level of patient care while ensuring affordability and continuously improving health outcomes for our community," said Peter L. Slavin, MD, president and CEO of Cedars-Sinai Health System. "By working closely with Blue Shield, we are helping to build a more connected and equitable healthcare system that truly serves the people of Southern California." More news. August 11, 2026
Blue Shield of California has appointed Kedar S. Mate, MD, to its board of directors. Dr Mate is chief medical officer of Qualified Health AI, a digital health company focused on helping healthcare organisations deploy artificial intelligence technologies. He previously served as president and CEO of the Institute for Healthcare Improvement. Dr Mate brings over 20 years of experience in healthcare quality, patient safety, and health system transformation. He has advised leading healthcare organisations and government agencies, including the World Health Organization and Centers for Medicare & Medicaid Services. Dr Mate is a senior scholar at Stanford University's Clinical Excellence Research Center and practises internal medicine at New York Presbyterian Hospital. Blue Shield of California is a nonprofit health plan with nearly 6 million members and over $28 billion in annual revenue.
Blue Shield of California appoints healthcare innovation leader Kedar S. Mate, MD, to... OAKLAND, Calif. (Aug. 10, 2026) - Blue Shield of California today announced the appointment of Kedar S. Mate, MD, a physician, healthcare quality... [gamipress_button label="Yes" class="thumbs-rating-up thumbs-rating" url="#gutenslider-pwsyfz0ki-3"] [gamipress_button label="No" class="thumbs-rating-down thumbs-rating" url="#gutenslider-pwsyfz0ki-3"] Based on recent headline ratings, 89% of this readership currently trusts the local media, which has an average score of 89% regionally and is currently trending negative. Media Trust Score
Blue Shield of California's BlueSky Youth Mental Health initiative earns national North Star Award. Blue Cross Blue Shield Association honors Blue Shield's statewide effort to expand mental health support for young people. July 29, 2026 by Laine Himmelmann Blue Shield of California's BlueSky youth mental health initiative has received the Blue Cross Blue Shield Association's prestigious 2026 North Star Award in the Healthier Lives for Members and Local Communities category, recognizing its efforts to expand youth mental health support across California. The North Star Awards honor outstanding programs and initiatives across the Blue Cross and Blue Shield system that create meaningful impact for members and local communities. "Strong mental health begins in childhood and lays the foundation for lifelong well-being," said Mike Stuart, president and CEO of Blue Shield of California. "Nearly 1 in 4 U.S. adults have experienced a mental illness in the past year. Mental health challenges can increase the risk of chronic disease and poorer health outcomes later in life, which is why investing in youth mental health is one of the most important ways we can improve the long-term health of our communities. We're honored to receive this recognition and proud to work alongside schools, community organizations, educators, and young people to expand access to care and help more Californians thrive." Blue Shield launched BlueSky in 2019 after California received a D grade in youth mental health from Children Now, a nonprofit dedicated to children's public policy issues. Since then, the BlueSky initiative has grown into a statewide effort focused on improving emotional well-being for young people through school-based and virtual mental health services, educator training, and youth-led advocacy programs, particularly in underserved communities. The need remains urgent. Blue Shield's 2025 BlueSky Youth Mental Health Survey found that 94% of California Gen Z youth report regularly struggling with mental health challenges. "The mental health challenges facing California's youth demand action from all of us," said Dr. Deneen Vojta, executive vice president of Healthcare Quality and Affordability at Blue Shield of California. "Through BlueSky, we're connecting young people to care sooner by meeting them where they are, equipping trusted adults with the tools to respond, and making sure youth voices help shape solutions. That's how we create lasting change." Since its launch, BlueSky has: * Supported more than 30,000 youth and educators through on-campus and online mental health services, educator training, and youth-driven advocacy programs * Delivered 30,543 individual, family, group, and crisis-intervention therapy sessions through its collaboration with nonprofit Wellness Together * Trained more than 9,000 educators and caring adults in Youth Mental Health First Aid in partnership with the California Department of Education, with 95% reporting confidence in supporting youth in distress * Helped expand the National Alliance on Mental Illness (NAMI) California's youth-led mental health club network to more than 170 clubs statewide, empowering thousands of students to reduce stigma, build peer support, and raise awareness of mental health resources A cornerstone of BlueSky is its commitment to youth leadership. Through school clubs, advocacy programs, and statewide engagement opportunities, young people help shape program priorities, outreach efforts, and emerging mental health solutions. Blue Shield is also a recurring sponsor of NAMI California's Youth Advocacy Day, which brings hundreds of students to the State Capitol each year to engage policymakers and advocate for stronger youth mental health support. "The success of BlueSky is deeply rooted in the voices of the young people it serves," said Frank Caporusso, senior vice president of Healthcare Quality and Affordability Operations at Blue Shield of California. "By listening to youth and our members, we're able to design behavioral health programs that respond to real needs. We are proud of what BlueSky has accomplished so far, and we're committed to continuing this work so more young people have the support and resources they need to thrive." The national North Star Award recognition highlights BlueSky's collaborative, community-based approach to addressing the youth mental health crisis by bringing together schools, nonprofits, educators, and young people themselves. Watch this video to hear directly from California youth about BlueSky's impact.
Blue Shield of California has been named a "World's Top Disability Inclusive Business" by the Disability Index, earning a top score for 2026. The nonprofit health plan was recognised during Disability Pride Month for its commitment to advancing disability inclusion. The Disability Index evaluates organisations across nine areas, including culture, leadership, accessibility, benefits, recruitment, career development, supply chain, accommodations, and marketing. Blue Shield's score reflects its efforts to embed accessibility throughout the organisation. The health plan serves nearly 6 million members and employs 6,800 people, with more than $28 billion in annual revenue. Founded in 1939, Blue Shield of California provides health, dental, vision, Medicaid, and Medicare healthcare service plans.