Risk Analytics

Optum^® Risk Analytics is a comprehensive risk adjustment analytics platform designed to help health plans and provider organizations turn complex patient data into actionable insights that can help improve coding and risk adjustment accuracy and care quality. The platform consolidates large volumes of data, identifies clinical gaps, uncovers suspected conditions, and helps support accurate, complete documentation of chronic conditions. It enables organizations to evaluate risk drivers, stratify populations, and take informed action to help improve risk adjustment outcomes.

By transforming raw data into prioritized insights — including suspected diseases, prevalence trends, and provider recapture rates — the platform helps risk adjustment teams improve coding completeness and supports more accurate reimbursement through enhanced visibility into population health risks.

Optum Risk Analytics gives organizations the tools to launch, manage, and track risk adjustment campaigns within a single application. Users can run prospective, concurrent, and retrospective campaigns supported by risk adjustment suspecting, member stratification, and gap analytics. The system generates targeted chase lists focused on high‑risk members and provides customizable reporting across campaign performance metrics, member‑level insights, and provider‑level results.

A full suite of customizable reporting dashboards enables deeper visibility into eligible members, suspected vs. captured Hierarchical Condition Categories (HCCs), disease gap trends, and overall campaign effectiveness. Organizations can filter and tailor reports to support operational planning, coding accuracy, and performance improvement initiatives.

Risk Analytics uses member and provider stratification models informed by extensive clinical and demographic data—such as risk scores, disease gaps, eligibility, prevalence, provider types, and Social Determinants of Health (SDOH) factors—to identify the individuals and organizations with the highest potential impact on quality and cost.

The platform enables the creation of member cohorts based on social determinants of health, highlighting segments that may need additional resources or clinical interventions. It also prioritizes high‑risk members for chase lists, supporting targeted outreach and clinician alignment to help improve documentation accuracy and care delivery.

By ingesting and analyzing large volumes of patient data, the platform identifies gaps in care—including members with no provider visits, missed wellness visits, or unmanaged chronic conditions. These insights enable care teams to intervene earlier, coordinate targeted care plans, and assist with disease prevention.

Earlier identification of emerging risks supports proactive care management strategies that reduce avoidable utilization, enhance patient engagement, and can help improve long‑term outcomes across both value‑based care and quality programs.

Optum Risk Analytics provides real‑time, data‑driven insights by ingesting large datasets and extracting key risk trends such as suspected diseases, average risk scores, provider recapture rates, and member‑level risk indicators. This real‑time processing helps organizations quickly identify changes in population health risk and act on timely opportunities to improve documentation completeness and close care gaps.

These insights empower teams to optimize campaigns, refine outreach strategies, and effectively plan ahead by estimating potential risk score changes and assessing the impact of new Hierarchical Condition Categories (HCC) mappings or coding adjustments.

Risk Analytics, our advanced risk adjustment analytics and suspecting solution, gives health plans and providers a quick and efficient method to identify individuals who may benefit from a provider visit. The sophisticated analytics can even uncover suspected conditions that have not yet been diagnosed. With this knowledge, health plans and providers can reach out to patients and initiate early interventions, which can often make the difference between a desirable health outcome and costly hospitalizations.

The robust analytics available in Risk Analytics are an invaluable resource to help providers and healthcare organizations identify and close gaps in care. You can efficiently scan patient/member data to locate patients with chronic conditions who are overdue for provider visits. By analyzing past patient history, Optum Risk Analytics can also help identify   likely conditions that have not yet been diagnosed. This information allows for proactive outreach to encourage patients to see their provider before conditions become critical.