Risk Adjustment Strategic Manager

• Assists management by overseeing day to day operations for risk adjustment programs including both prospective and retrospective, claims, vendor quality, and audits.
• Develops metrics, policies, and procedures in support of required deliverables and validation of programs return on investment while ensuring the programs are in compliance with Center for Medicare and Medicaid Services (CMS) program requirements.
• Serves as a strategic partner to the business and contributes to ideas and solutions.
• Influences others and works effectively to establish and develop working relationships both internally and externally with business stakeholders.
• Obtains and complies trend data and educates providers.
• Collaborates with the operations risk and compliance teams in implementing and deploying Enterprise Risk and Compliance initiatives, processes, and tools.
• Effectively drives remediation of risks and issues by collaborating with Business Operations, Internal Audit and Regulatory Compliance.
• Finds root cause and recommends innovative solutions.
• Provides oversight and ensures complete and accurate coding for Medical Revenue Management programs driving the revenue we receive from CMS.
• Serves as a subject matter expert on coding.
• Leads and consults with operations on ad hoc requests/special projects.
• Works collaboratively with Enterprise Risk Adjustment team, Business Operations, Regulatory Compliance, and Internal Audit.
• Oversee daily operations of risk adjustment programs across prospective and retrospective initiatives.
• Provide oversight of provider engagement, provider education, data submissions, vendor quality performance, and audit activities.

• Requires a BA/BS in a related field and minimum of 5 years of experience in a managed care setting with extensive risk adjustment experience with a focus on CMS audit experience; or any combination of education and experience, which would provide an equivalent background.

• Coding knowledge strongly preferred.

• MBA or MHA in Healthcare Administration preferred.
• Experience working on the payer side of the health insurance industry strongly preferred.
• Strong understanding of risk adjustment models, including: Medicare Advantage, Medicaid, ACA Commercial is preferred.
• Knowledge of value-based care providers and provider reimbursement models preferred.
• Experience working directly with providers and/or provider group leadership strongly preferred.
• Preferred background in Clinical Documentation Improvement (CDI) and medical coding practices.
• Certified coder credential preferred (e.g., CPC, CRC, CCS, RHIT, RHIA).
• Executive-level communication and presentation skills preferred.
• Moderate to advanced proficiency in Microsoft Excel, Tableau, or other data reporting and analytical tools preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on aplitrak.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act