Manager Risk Mitigation

Job Summary

The Manager, Risk Mitigation is the thought leader role responsible for the design, implementation, and execution of auditing programs ensuring the accuracy, compliance, and integrity of risk adjustment processes. This role mitigates financial, operational and compliance risks through proactive audits, data validation, internal controls oversight and cross‑functional collaboration. This leader initiates and implements overall strategic direction set by the VP and Director of Prospective Operations and Risk Mitigation, as well as other Directors of Risk Adjustment.

The role is responsible for helping to achieve the risk adjustment program vision, strategies, objectives, and goals. This includes leading a team responsible for ensuring the accuracy, compliance, and integrity of all risk adjustment coding and documentation reviews both retrospectively and prospectively for the Health Plan. Additionally, the Risk Mitigation Manager is responsible for monitoring targets; leading teams in analyzing, reporting, and forecasting key risk adjustment metrics;

managing risk adjustment vendors; as well as, ensuring new legislation and regulations regarding risk adjustment are properly understood and accounted for. Lastly, the role directly supports the Director Prospective Operations and Risk Mitigation in identifying, developing, promoting and executing process improvement strategies and priorities to reduce redundancies, ensure maximum efficiencies, align with other Priority Health systems and processes, as well as to ensure appropriate policies and procedures exist.

• Manages the daily workflow of Risk Mitigation Team which includes managing the full lifecycle of retrospective coding audits, prospective documentation and coding reviews, vendor audit oversight, RADV, IPM, OIG, IVA, and other regulatory audits. Follows the strategic direction and implements risk adjustment initiatives required to achieve the business goals and objectives. Assists leadership in identifying, assessing and prioritizing risks related to coding, data accuracy, provider documentation and compliance with CMS/HHS requirements.
  
  Develops and implements risk mitigation strategies and process improvements to reduce audit exposure. Draft actionable audit observations & recommendations to strengthen controls and reduce compliance risk.
• Responsible for monitoring and managing Risk Mitigation staff quality and productivity by conducting regular 1:1s, performance evaluations, calibration sessions, and competency assessments to ensure quality and accuracy requirements are being met. Additionally, set and manage productivity and quality benchmarks by chart type and coder level. Provide a summary of productivity and quality findings on a regular cadence, and provide coaching and feedback on achieving production and quality standards of the role.
  
  Ensures high‑quality, on‑time audit deliverables.
• Establish and/or update policies and procedures as necessary to ensure coding accuracy and productivity, improve efficiencies, and minimize risk in audits for the health plan and ensuring accurate risk score capture. Monitor risk adjustment performance indicators such as RAF accuracy, prevalence rates and audit error rates. Ensure adherence to CMS, HHS, and state specific risk adjustment regulations by maintaining expert level knowledge of existing HCC models (both medical & Rx for all applicable LOB) and maintaining knowledge of model changes, coding guideline updates, and RADV requirements, serving the organization as the SME.
  
  Identify compliance risks and establish and implement corrective action plans under the supervision of the Director of Prospective Operations and Risk Mitigation.
• Responsible for the development of actionable training materials, onboarding materials, reporting metrics, including scorecards for both internal and external stakeholders. Analyze error patterns and trends to aid in the development of training materials. Motivate team members through effective training, supplemental materials and coaching to improve quality and production.
• Communicate Risk Adjustment program to internal & external…