Building a Population Health Risk Stratification Pipeline for MA Plans

Short summary

A practical architecture for building a Medicare Advantage population health risk stratification pipeline using layered signals: a defensible RAF base under CMS-HCC V28 plus supplemental utilization and care-gap overlays. The author emphasizes explainability over black-box models, transparent tiering logic, and feeding stratification results back into documentation workflows. Rising-risk members are highlighted as the highest-ROI tier for targeted outreach.

• •Layered risk scoring: RAF base + utilization and care-gap overlays for MA plans
• •Explainability is critical — care managers and auditors need defensible scores
• •Rising-risk tier drives most ROI; pipeline should emit documentation gap work items

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