Risk Adjustment Manager - Prospective (Hybrid)

Purpose

The Risk Adjustment Manager plays a critical role in developing and executing CareFirst’s corporate risk adjustment strategy, focusing on Medicare Advantage, Medicaid, and ACA markets. The role serves as a dedicated resource for prospective risk adjustment, improving diagnosis capture accuracy, member risk score performance, and risk‑adjusted revenue outcomes. The position is based in the greater Baltimore/Washington metropolitan area and operates in a hybrid model, with a portion of the week working from home and at least two days on‑site at a CareFirst location as business needs dictate.

Essential Functions

• Lead the development and execution of prospective risk adjustment strategies to improve diagnosis capture accuracy, member risk score performance, and risk‑adjusted revenue across all lines of business.
• Establish and monitor key performance indicators (KPIs), objectives and key results (OKRs), return on investment (ROI), program milestones, and operational dashboards.
• Communicate program performance, risks, opportunities, and action plans to senior leadership and drive accountability for achieving organizational goals.
• Develop and oversee provider‑facing risk adjustment programs focused on clinical documentation, coding accuracy, condition recapture, and prospective diagnosis capture.
• Lead provider engagement strategies, incentive programs, point‑of‑care initiatives, educational campaigns, and vendor partnerships.
• Collaborate with network management, provider relations, clinical teams, and external partners to expand provider participation and improve program effectiveness.
• Assess the operational and financial impact of evolving risk adjustment regulations, methodologies, and industry practices; develop implementation strategies to ensure compliance while optimizing business outcomes.
• Serve as a subject matter expert for financial forecasting, bid development, revenue performance analysis, regulatory filings, and strategic planning.
• Partner with internal and external stakeholders—including regulators, industry organizations, and cross‑functional business leaders—to advance organizational objectives and identify opportunities for program enhancement.
• Act as a liaison between business units and the risk adjustment group, promoting collaboration and excellent customer service.
• Guide key stakeholders in bid filings, regulatory filings, and financial performance planning and reporting.

Supervisory Responsibility

This position manages people.

Qualifications

• Education: Bachelor’s degree required; alternatively, an additional four years of relevant work experience may substitute for the degree.
• Experience: Minimum five years of progressive responsibility in a healthcare payer environment, including at least one year of supervisory or demonstrated leadership experience within Government Programs and Risk Adjustment functional areas.
• Preferred: Master’s degree in Business Administration, Health Administration, or Public/Population Health.
• Certification: Successful completion of a coding certificate program from an accredited organization (e.g., CPC, CRC, CPMA from AAPC, or CCS, CCS‑P from AHIMA).

Knowledge, Skills, and Abilities

• Comprehensive knowledge of all regulatory guidelines governing risk adjustment.
• Proven ability to plan and lead presentations to physicians, internal stakeholders, and C‑suite executives with a focus on coding data and analytics.
• Experience delivering effective physician/provider collaborative training to support workflow adjustments and improve clinical coding quality.
• Strong leadership and vendor‑oversight capabilities, with experience in payer, provider, and industry collaboration.
• Ability to thrive in a fast‑paced, matrixed environment, meet established deadlines, and manage multiple customer‑service demands.
• Exceptional communication and customer‑service skills, including the ability to provide positive service to demanding or challenging internal and external customers.

Salary Range

$105,040 – $194,981 (range reflects scope and responsibilities of the position; actual compensation will consider experience, internal equity, location, and other factors).

Benefits

CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401(k) contribution programs/plans, all subject to eligibility requirements.

Physical Demands

The associate is primarily seated while performing duties, with occasional walking or standing. Hands are regularly used to write, type, and manipulate small controls. Frequent talking and hearing are required. Occasionally lifts weights up to 25 pounds.