Head of Risk Management & Audit

Job Description Description: Mass Advantage is a Medicare Advantage health plan, located in the heart of Worcester County, headquartered in Worcester MA. Mass Advantage is owned and designed by UMass Memorial Health providers with their patients’ needs in mind.

We are looking for a Manager of Risk Managment to oversee Mass Advantages's full suite of Risk Adjustment activities. This position is responsible for the strategy, execution and performance of Medicare risk adjustment programs, infrastructure and systems to meet business objectives, revenue expectations, management of external vendors, interaction with Providers, regulatory audits, and compliance with CMS regulations. The Manager of Risk Management is also responsible for analysis, projections, and assessment of Medicare revenue initiatives for senior products; leading and coordinating enterprise risk adjustment initiatives, working with the necessary areas of Mass Advantage and UMass Memorial Health Operations as well as vendor partners.

Own end-to-end RA strategy across prospective (point-of-care capture, suspecting, provider workflows) and retrospective (chart review, coding validation) programs, ensuring complete, accurate, and compliant HCC documentation under the applicable CMS-HCC model (including V24 -V28 transition management).
Evaluate current vendor performance, renegotiating or sunsetting SOWs where internal capability is superior.
Serve as the plan-side counterpart to UMMH CDI, HIM, and Coding leadership, coordinating with the CMO's office to embed documentation workflows into Epic-based clinical practice rather than layered on top of it.
Partner with Network and Clinical Services to design provider-facing education, scorecards, and incentive structures that drive documentation accuracy without creating coding-driven behavior.
Develop provider-level performance reporting that is transparent, defensible, and actionable.
RADV, Audit & Compliance
Lead RADV audit readiness and response, including medical record retrieval, validation, submission strategy, and cross-functional coordination with Legal, Compliance, and Finance to mitigate financial and compliance risk.
Maintain a comprehensive QA program covering RADV, OIG, and internal audits — monitoring the work of internal coders, contracted vendors, and provider documentation alike.
Own encounter data integrity, including EDPS submission accuracy, RAPS/EDPS reconciliation, and error resolution.
Analytics, Finance & Bid Support
Build and maintain the RA analytics layer — dashboards, KPIs, and provider/member-level reporting that drive continuous improvement in risk score accuracy, coding yield, and program ROI.
Partner with Actuarial and Finance on bid development, producing defensible risk score projections, trend analysis, and revenue assumptions grounded in population severity and program performance.
Set departmental goals, budgets, and tactical plans aligned with enterprise strategy and financial targets.
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Bachelor's degree in a relevant field; Master's (MBA, MHA, MPH) preferred.

• CRC (Certified Risk Adjustment Coder), CPC, or CCS certification preferred.
• 7+ years in Medicare Advantage risk adjustment, with at least 3 years in a plan-side role (not solely provider-side or vendor-side).
• Direct, hands-on RADV experience - working fluency with the CMS-HCC model, including the V24-V28 transition and its financial implications.
• Demonstrated experience managing or transitioning RA vendors (coding, chart retrieval, in-home assessment).
• Strong analytical skills: able to interrogate data directly in SQL, Power BI, or Tableau, or to spec analytics requirements with precision.+
• Strong Microsoft Office skills (Word, Outlook, Excel and PP).