REMOTE - Quality Risk Adjustment Advisor IV (Health Plan experience required) - R13035

Job Summary

The Quality Risk Adjustment Advisor IV is responsible for leading key components of the Quality Risk Adjustment (QRA) programs, including prospective programs, chart retrieval and coding processes, while ensuring compliance with regulatory standards and optimizing quality outcomes. This role partners closely with internal stakeholders and external vendors to enhance operational effectiveness and leverage artificial intelligence (AI) technologies to improve data accuracy, efficiency, and overall program performance.

About the Role

This role serves as a subject matter expert in Risk Adjustment operations, supporting prospective programs, chart retrieval and coding processes. It involves identifying and recommending strategies to optimize risk adjustment processes and improving quality metrics across insourced and outsourced activities, including leveraging AI for process enhancement.

Responsibilities

• Serve as a subject matter expert in Risk Adjustment operations, supporting prospective programs, chart retrieval and coding processes.
• Identify and recommend strategies to optimize risk adjustment processes and improve quality metrics across insourced and outsourced activities, including leveraging AI for process enhancement.
• Partner with vendors to support execution of operational production plans and contractual requirements.
• Monitor vendor performance and identify opportunities to improve efficiency, quality, and cost management.
• Collaborate with QRA Compliance to support development and maintenance of quality assurance protocols.
• Conduct audits and assessments to ensure accuracy, completeness, and efficiency.
• Research and evaluate technological solutions, including AI/NLP tools.
• Partner with Data Science, IT, and Sourcing teams to support deployment of AI solutions.
• Collaborate with cross-functional teams to support operational goals.
• Identify and implement process improvements.
• Monitor and analyze key performance indicators (KPIs).
• Gather and translate business requirements into actionable recommendations.
• Assess build vs. buy AI solutions.
• Support evaluation and monitoring of AI solution performance.
• Provide guidance and informal coaching to stakeholders as needed.
• Perform any other job related duties as requested.

Requirements

• Bachelor's degree in Health Administration, Healthcare Management, or a related field required. Master's degree is preferred.
• Equivalent years of relevant work experience may be accepted in lieu of required education.
• Seven (7) years experience in risk adjustment, medical record review, coding, or quality management required.
• Two (2) years experience with AI solutions in a healthcare setting required.

Qualifications

• Knowledge of ICD-10 Coding
• Knowledge of HCC Risk Adjustment models
• Knowledge of CMS regulatory guidelines
• Strong analytical and problem-solving skills
• Ability to apply AI technologies in healthcare
• Strong communication and collaboration skills
• Ability to influence stakeholders without direct authority

Skills

• Knowledge of ICD-10 Coding
• Knowledge of HCC Risk Adjustment models
• Knowledge of CMS regulatory guidelines
• Strong analytical and problem-solving skills
• Ability to apply AI technologies in healthcare
• Strong communication and collaboration skills
• Ability to influence stakeholders without direct authority

Education

• Bachelor's degree in Health Administration, Healthcare Management, or a related field required. Master's degree is preferred.

Experience

• Seven (7) years experience in risk adjustment, medical record review, coding, or quality management required.
• Two (2) years experience with AI solutions in a healthcare setting required.

Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

Working Conditions

General office environment; may be required to sit or stand for extended periods of time. Travel is not typically required.

Compensation

Compensation Range: $83,000.00 - $132,800.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance.

We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.