Risk Adjustment Strategic Manager

Responsibilities

• Oversee day-to-day operations and strategic execution of enterprise risk adjustment programs
• Assist management overseeing risk adjustment programs including claims, vendor quality, and audits
• Develop metrics, policies, and procedures for validation of programs return on investment
• Collaborate with operations risk and compliance teams for implementing initiatives
• Provide oversight and ensures accurate coding for Medical Revenue Management programs
• Serve as a subject matter expert on coding
• Work collaboratively with Enterprise Risk Adjustment team, Business Operations, Regulatory Compliance, and Internal Audit
• Influence others and work effectively to develop relationships with stakeholders

• Requires a BA/BS in related field
• Minimum of 5 years experience in managed care setting
• Extensive risk adjustment experience
• Experience with CMS audit
• Coding knowledge strongly preferred
• MBA or MHA in Healthcare Administration preferred
• Experience working on payer side of health insurance industry preferred
• Strong understanding of risk adjustment models including:
  Medicare Advantage, Medicaid, ACA Commercial preferred
• Knowledge of value-based care providers and provider reimbursement models preferred
• Experience working directly with providers and/or provider group leadership preferred
• Preferred background in Clinical Documentation Improvement (CDI) and medical coding practices
• Certified coder credential preferred (e.g. CPC, CRC, CCS, RHIT, RHIA)
• Moderate to advanced proficiency in Microsoft Excel, Tableau, or other data reporting and analytical tools preferred.