Senior Manager, Risk Adjustment
Job Summary
The Sr. Risk Adjustment Manager is responsible for leading and optimizing risk adjustment operations across all lines of business and entities, including Medicare Advantage, Marketplace, and other affiliated health plans, medical groups, and MSO functions. This role serves as a subject matter expert on federal risk adjustment regulations, policies, and methodologies.
Essential Job Functions
Lead Risk Adjustment Strategy & Operations: Oversee the development, implementation, and continuous improvement of risk adjustment programs across all lines of business, including Medicare Advantage (CMS-HCC), Marketplace (HHS-HCC), and RxHCC models, ensuring regulatory compliance, coding accuracy, and risk score optimization.
Stay Current on Model Versions & Methodologies: Maintain deep expertise in CMS-HCC model updates (e.g., V24 vs. V28), RxHCC methodology for Medicare Part D, and HHS-HCC annual model recalibrations, including normalization factors, coding intensity adjustments, and future model transitions as released in CMS Advance Notices and Final Rate Announcements.
Manage Department Staff & Cross-Functional Teams: Provide strategic direction and oversight for Risk Adjustment and coding department staff. Assemble and lead cross-functional and ad hoc teams for specific initiatives such as RADV audit readiness, encounter accuracy improvement, and provider education.
Build and Manage Risk Adjustment Reporting & BI Tools: Design, implement, and maintain dashboards and reporting tools to monitor performance metrics such as risk score trends, gap closure rates, encounter completeness, RxHCC attribution, and audit readiness benchmarks.
Conduct Data Gap Analysis & Targeted Program Design: Perform thorough analyses to identify documentation, coding, and encounter data gaps. Use findings to develop targeted retrospective and prospective strategies to improve risk capture and data completeness, especially in hard-to-reach or low-utilization populations.
Partner with provider groups, ACOs, MSOs, and vendors to ensure alignment with risk adjustment documentation and coding guidelines. Design and monitor clinical documentation improvement (CDI) initiatives to capture accurate and complete conditions, including RxHCC-relevant conditions.
Manage Vendor Relationships & Contractual Performance: Oversee vendor selection, contracting, performance monitoring, and ensure vendors are compliant with CMS, HHS, and HIPAA regulations. Evaluate results of chart review, in-home assessment, and coding audit programs to ensure ROI and coding accuracy.
Translate CMS and HHS guidance (e.g., Final Rule, Advance Notice, DIY Instructions) into actionable operational processes. Ensure that all risk adjustment activities are aligned with evolving federal and state policy, including rules around telemedicine, audio-only visits, data submission, and model-specific filtering logic.
Lead internal readiness for RADV (Risk Adjustment Data Validation) audits, including targeted coding audits, sampling validation, and documentation retrieval strategies. Ensure processes are in place to support both CMS RADV and HHS IVA audit requirements.
Analytics, Benchmarking & Forecasting: Utilize predictive analytics, industry benchmarks, and statistical modeling to assess financial and coding performance, forecast risk scores, and evaluate the impact of coding pattern adjustments (CPA), dual status, and symmetric caps.
Integrate HCC, RxHCC, and HEDIS Data Across Systems: Collaborate with internal data, quality, and clinical teams to align risk adjustment with HEDIS initiatives, STAR measure improvement, and RxHCC data submission processes. Ensure accurate crosswalks between claims, EHR, and supplemental data sources.
Provider & Staff Education: Develop and lead training programs for internal staff and network providers on CMS-HCC, HHS-HCC, and RxHCC requirements, documentation best practices, model changes, and audit implications. Use CMS and industry educational resources such as the MLN, EDGE DIY instructions, and model release notes.
Data Quality Oversight: Ensure ongoing monitoring and quality assurance of encounter data, HCC coding, supplemental data submissions, and RxHCC files. Validate data submitted to CMS (e.g., RAPS, EDPS, PDE files) and HHS (e.g., EDGE server).
Audit & Regulatory Compliance: Maintain compliance with HIPAA, CMS and HHS regulations, ensuring all operational, coding, and documentation standards align with federal and contractual obligations.
Operational Oversight & Performance Management: Maintain regular operational reviews, enforce adherence to submission timelines (e.g., initial/mid-year/final sweeps), and ensure alignment with organizational goals for revenue accuracy and regulatory performance.
Marginal Job Functions
Leads or supports special projects and initiatives as assigned to meet organizational goals.
Position Requirements
Education/Experience: Bachelor’s degree required; equivalent combination of education and relevant experience may be considered in lieu of a degree. Minimum 5–7 years of progressive experience in Risk Adjustment, with hands-on expertise in CMS-HCC and HHS-HCC program operations, coding, analytics, and regulatory compliance. At least 3 years of supervisory or managerial experience, preferably leading cross-functional teams and/or vendor management in a health plan or provider organization.
Skills/Knowledge/Ability: Strong knowledge of the U.S. healthcare system, including Medicare Advantage and ACA Marketplace programs, with working familiarity of claims data, encounters, eligibility, and risk adjustment methodologies. Proficient in Microsoft Office Suite (Excel, Word, Access) and SQL for data analysis, reporting, and ad hoc queries. Demonstrated experience leading and implementing process improvements and system enhancements in a healthcare or risk adjustment setting. Excellent verbal and written communication skills in English, with the ability to convey technical and regulatory information clearly to both internal teams and external partners. Proven ability to interact professionally and collaboratively with members, providers, vendors, and cross-functional teams. Strong organizational and time management skills, with the ability to prioritize multiple tasks, manage shifting priorities, and meet deadlines in a dynamic environment. Sound judgment and decision-making skills, with the ability to solve problems independently and escalate appropriately. Committed to maintaining confidentiality, privacy, and regulatory compliance, including adherence to Federal, State, and HIPAA regulations. Adaptable, team-oriented, and able to work both independently and as part of a collaborative team.