JD

Risk Stratification

Population segmentation by clinical risk tier with care management assignment tools

High Risk
847
10% of population
Rising Risk
1,686
20% of population
Moderate Risk
2,530
30% of population
Low / Stable
3,369
40% of population
Risk Tier Metrics
Average values per tier for care planning insights
TierPatientsAvg RAFAvg PMPMCM Enrolled
High8472.84$2,14091%
Rising1,6861.62$1,12048%
Moderate2,5300.98$68012%
Low3,3690.54$3202%
Risk Score Distribution
Member count by RAF score band
1240
0.0-0.5
2129
0.5-1.0
2130
1.0-1.5
1300
1.5-2.0
900
2.0-2.5
490
2.5-3.0
243
3.0+
Risk Model Factors
Data domains used to compute risk tier scores
Claims-Based (45% weight)
Inpatient admitsER visitsSpecialist utilizationChronic diagnosesPrior auth frequency
Clinical (30% weight)
Lab values (A1C, eGFR)BMI trendsVital signsFunctional status
Pharmacy (15% weight)
Polypharmacy (≥8 meds)PDC adherenceHigh-risk medications
Social Determinants (10% weight)
Housing instabilityFood insecurityTransportation barriersSocial isolation score
High Risk Patient List
Showing 847 members — filtered to High Risk tier
Patient NameRAF ScoreTop DiagnosesLast ContactCare ManagerAction
Maria Gonzalez3.12CHF, CKD Stage 4, T2DMMar 28, 2026Sarah Kim
James Whitfield2.98COPD, CAD, DepressionMar 22, 2026Tom Reeves
Dorothy Chen2.87Stroke, HTN, Atrial FibrillationMar 15, 2026Unassigned
Robert Ashby2.71T2DM, Obesity, HTNMar 10, 2026Linda Park
Helen Torres2.65CKD Stage 3, T2DMFeb 28, 2026Unassigned
Frank Mason2.54CHF, COPD, DepressionMar 5, 2026Sarah Kim
Carol Okafor2.41CAD, HTN, HyperlipidemiaMar 20, 2026Tom Reeves
William Sanders2.38ESRD, HTN, AnemiaMar 18, 2026Linda Park
Showing 8 of 847 high-risk members
Page Guide

Risk stratification segments the enrolled population into four tiers based on a composite algorithm using claims, clinical, pharmacy, and social determinant data.

Click any tier card to filter the patient list to that tier.

  • Select multiple patients using checkboxes
  • Use "Assign Care Manager" to bulk-assign from the header button
  • Click "View" to open the patient detail page
  • Filter by tier using the dropdown selector

The risk score is computed nightly. Four data domains contribute weighted inputs:

  • Claims (45%): Utilization patterns, diagnoses
  • Clinical (30%): Lab values, vitals, functional status
  • Pharmacy (15%): Adherence, polypharmacy
  • SDOH (10%): Social risk factors

Select rows with checkboxes to enable bulk operations. Available bulk actions include:

  • Assign or reassign care manager
  • Send outreach message
  • Export selected members
  • Flag for medical review

The histogram shows member distribution across RAF (Risk Adjustment Factor) score bands. RAF scores above 2.0 indicate high-complexity patients requiring intensive management.