Importance Solid organ transplant (SOT) recipients are at increased risk for skin cancer due to long-term immunosuppression. However, this risk is heterogeneous across the SOT population. The Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) incorporates established clinical risk factors to stratify SOT recipients into low-, medium-, high-, and very high−risk groups for posttransplant skin cancer. Objective To assess skin cancer risk among SOT recipients and to evaluate the impact of a modified SUNTRAC-based surveillance program on screening rates, skin cancer incidence, and health care resource utilization. Design, Settings, and Participants This was a retrospective cohort study of adult patients (≥18 years) who underwent SOT from January 1, 2016, to March 31, 2023. SOT recipients and nonrecipients were identified from the transplant registry of Kaiser Permanente Northern California (KPNC), an integrated health care delivery system providing care to more than 4.5 million members. SOT recipients were matched 1:20 on sex, race and ethnicity, and medical facility with nonrecipients. The study period was divided into preimplementation of the modified SUNTRAC (ie, KP-SUNTRAC) program (2016-2021) and postimplementation (2022-2024) periods. Included participants were followed up through March 31, 2024. Data were analyzed from July 2024 to June 2025. Exposure Implementation of KP-SUNTRAC risk-based skin cancer surveillance program. Main Outcomes and Measures Among SOT recipients, the number of skin cancer screenings; skin cancer incident rates for basal cell carcinoma, cutaneous squamous cell carcinoma, cutaneous melanoma, or Merkel cell carcinoma; and health care resource utilization, measured by dermatology and nondermatology encounters and pathology specimen counts. Results The analysis included 2083 SOT recipients matched with 26 199 nonrecipients and found a 7.8-fold increased risk of developing skin cancer posttransplant among the SOT recipients compared with nonrecipients (hazard ratio [HR], 7.78; 95% CI, 5.97-10.10). After KP-SUNTRAC implementation, the risk of first detected skin cancer was significantly higher in the postimplementation group (HR, 2.57; 95% CI, 1.76-3.73). During the postimplementation period, screening rates significantly improved among the high-risk (HR, 1.98; 95% CI, 1.39-2.82) and very high−risk (HR, 2.17; 95% CI, 1.21-3.86) groups compared with preimplementation. Health care utilization did not increase after KP-SUNTRAC implementation. Conclusions and Relevance This cohort study found that KP-SUNTRAC was associated with improved skin cancer screening rates and detection among SOT recipients at higher risk of developing skin cancer, without increasing short-term health care utilization. This targeted surveillance approach supports timely diagnosis and has the potential to reduce morbidity and future health care costs.