Manager — HCC; Hierarchical Categories

Position: Manager — HCC (Hierarchical Condition Categories)
The client is looking at hiring a Manager — HCC (Hierarchical Condition Categories)  with experience across  concurrent, retrospective, and prospective review programs .

Department:  Risk Adjustment / Coding & Quality

Role

Summary:

The HCC Manager will lead end-to-end risk-adjustment operations, driving accuracy, compliance, and performance across concurrent, retrospective, and prospective programs. This role oversees clinical coding teams, provider engagement, quality audits, vendor coordination, and analytics to ensure accurate capture of chronic conditions, compliant documentation, and optimized RAF outcomes.

Key Responsibilities:

Program Leadership:
Lead strategy and execution of  concurrent, retrospective, and prospective HCC programs .
Develop workflows, SLAs, and performance dashboards for each program type.
Coordinate with providers, coders, care management, and payers to close documentation gaps.

Concurrent Reviews:
Oversee real-time chart reviews and documentation support within active encounters.
Ensure timely physician queries and compliant documentation improvement practices.
Monitor risk capture and clinical alignment during ongoing patient care.

Retrospective Reviews:
Manage retrospective chart retrieval, coding accuracy audits, and reconciliation.
Partner with vendors and internal audit teams to validate HCC submissions.
Identify root causes of missed or inaccurate codes and implement corrective actions.

Prospective Programs:
Lead outreach initiatives for annual wellness and chronic care visits.
Use predictive analytics and suspect lists to prioritize high-value patients.
Support providers with documentation templates, education, and performance feedback.

Compliance & Quality:
Ensure coding compliance with CMS, RADV, OIG, and payer guidelines.
Establish QA processes, coder audits, and corrective training plans.
Maintain policy documentation and readiness for external audits.

Team Management:
Hire, train, coach, and performance-manage HCC coders and analysts.
Foster a culture of accuracy, accountability, and continuous improvement.

Analytics & Reporting:
Track RAF trends, gap closures, query response rates, and chart completion.
Present insights to leadership and recommend improvement strategies.
Support budgeting, forecasting, and ROI analysis for risk-adjustment initiatives.

Qualifications:

Bachelor’s degree in Healthcare Administration, Nursing, HIM, or related field (Master’s preferred).
8+ years of experience in HCC/risk adjustment , with at least  2–3 years in a leadership or managerial role .
Proven hands-on experience managing  concurrent, retrospective, and prospective HCC programs .
Current certification preferred:  CRC, CPC, CCS, CCS-P, RHIT, or RHIA .
Strong knowledge of ICD-10-CM, CMS HCC models, provider documentation guidelines, and RAF methodologies.
Experience collaborating with providers, payers, and third-party vendors.
Excellent analytical, leadership, and communication skills.

Preferred Experience:

Prior experience in US healthcare (Medicare Advantage strongly preferred).
Exposure to RADV audits, HEDIS/quality intersections, or CDI programs.
Familiarity with risk-adjustment platforms, EMR systems, and reporting tools.
Proven success improving RAF scores while maintaining compliance integrity.

Key Performance Indicators (KPIs):
RAF accuracy and improvement trends
Chart completion & retrieval turnaround
Query acceptance / response rates
Audit accuracy and error reduction
Provider engagement and training impact
Compliance & audit readiness metrics