Risk Adjustment Strategic Manager
Core
Overseeing day-to-day operations and strategic execution of enterprise risk adjustment programs, including prospective and retrospective initiatives, provider engagement, data submissions, and audit readiness.
Role type
Senior IC risk adjustment strategic manager
Builds
Operational excellence and compliance with CMS requirements for revenue integrity
Domain
Health insurance / Medicare Advantage / Medicaid / ACA Commercial
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
CMS audit experience, risk adjustment program operations, provider engagement, data submission management, vendor oversight, root cause analysis, coding oversight
Preferred skills
Medical coding knowledge, MBA/MHA, payer-side health insurance experience, risk adjustment models (Medicare Advantage/Medicaid/ACA), value-based care, Clinical Documentation Improvement (CDI), certified coder credentials (CPC/CRC/CCS/RHIT/RHIA), data reporting tools (Excel/Tableau)
Technologies
Microsoft Excel, Tableau
Responsibilities
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; Develop metrics, policies, and procedures to validate program return on investment; Serve as a strategic partner to business leadership to drive operational excellence and compliance; Collaborate with operations risk and compliance teams to implement Enterprise Risk and Compliance initiatives; Effectively drive remediation of risks and issues by collaborating with Business Operations, Internal Audit and Regulatory Compliance; Provide oversight and ensure complete and accurate coding for Medical Revenue Management programs
Seniority
Senior, hands-on IC
