Senior Manager, Risk Adjustment

Job Description

Job Description

JOB DESCRIPTION

JOB TITLE: Sr. Manager, Risk Adjustment FLSA STATUS: Exempt

DEPARTMENT: Quality Improvement and Risk Adjustment

REPORTS TO: Sr. Director, Quality Improvement, Risk Adjustment, and Health Analytics

AUTHORITY:

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. The position involves close collaboration with internal teams, providers, and external partners to improve risk score accuracy, provider engagement, and regulatory compliance. The Sr. Manager will also lead the development and operationalization of reporting tools, analytics, and workflows to support risk adjustment performance and data integrity across programs. This role plays a key part in aligning cross-functional teams, driving RADV audit readiness, and informing enterprise-level decisions related to financial forecasting, coding accuracy, and population health.

ESSENTIAL JOB FUNCTIONS:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. Provider and Vendor Collaboration: 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.
7. 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.
8. Regulatory Monitoring & Policy Implementation: 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.
9. RADV & Audit Preparedness: 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.
10. 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.
11. 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.
12. 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.
13. 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).
14. Audit & Regulatory Compliance: Maintain compliance with HIPAA, CMS and HHS regulations, ensuring all operational, coding, and documentation standards align with federal and contractual obligations.
15. 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:

1. Leads or supports special projects and initiatives as assigned to meet organizational goals.
2. Performs additional duties as required to support department and company objectives.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning & Professional Development

1. Actively participates in staff meetings, departmental updates, and organizational briefings.
2. Attends required trainings, conferences, and workshops to maintain knowledge of current regulatory standards, risk adjustment methodologies, and industry best practices
3. Pursues ongoing professional development to enhance leadership, technical, and compliance-related competencies

2. Customer Focus & Professional Conduct

1. Maintains the confidentiality and privacy of member and organizational data in accordance with HIPAA regulations and company policies
2. Demonstrates respect, professionalism, and courtesy in all interactions with members, providers, colleagues, vendors, and regulatory partners
3. Communicates clearly and effectively with team members and leadership to support collaborative problem-solving and high-quality service delivery

1. Quality, Compliance & Process Improvement

1. Proactively identifies and reports any concerns related to safety, compliance, data security, or operations to the appropriate leadership.
2. Adheres to all internal policies and procedures, as well as applicable federal, state, and contractual requirements
3. Supports and participates in continuous quality improvement initiatives, including process redesign, system enhancement, and performance optimization
4. Promotes a culture of safety, accountability, and compliance throughout daily operations and team activities

1. Ethics, Integrity & Accountability

1. Acts with integrity in all professional activities, upholding the organization’s mission, values, and code of conduct
2. Takes ownership of responsibilities, follows through on commitments, and holds self and others accountable for results
3. Maintains transparency and ethical decision-making in alignment with regulatory standards and organizational expectations

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
• Strong working knowledge of Medicare Advantage (CMS-HCC) and Marketplace (HHS-HCC) risk adjustment regulations, encounter data submission requirements, and model methodologies
• Experience with RxHCC risk models and PDE submission processes preferred
• Familiarity with RADV audits, HHS IVA audits, and CMS data submission protocols (e.g., RAPS, EDPS, EDGE)
• Prior experience collaborating with providers, vendors, and internal data/clinical teams to improve risk score accuracy and documentation quality

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

PREFERRED LICENSURE/CERTIFICATIONS/TRAININGS (NOT REQUIRED):

• Certified Risk Adjustment Coder (CRC) — AAPC
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS)
• Certified Clinical Research Auditor (CCRA)
• Project Management Professional (PMP) or Agile certification
• Certified in Healthcare Compliance (CHC) or similar compliance certifications
• Completion of CMS MLN risk adjustment training and EDGE server/HHS Marketplace risk adjustment modules
• Experience or certification in data analytics and business intelligence tools (e.g., SQL, Tableau, Power BI, SAS)
• RADV audit preparation
• Healthcare data privacy/security training
• Leadership and change management program completion