Manager Risk Adjustment Programs

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Manager Risk Adjustment Programs provides end-to-end management, delivery and support to new and existing MA and ACA Risk Adjustment Programs. Working closely with the Director, Risk Adjustment Programs, develop, executive and report-out on an annual risk adjustment strategy that delivers value to Capital Blue Cross and its beneficiaries enrolled in Risk Adjusted government programs. Supports other key objectives designed to build/strengthen patient care delivery and capture of Risk Adjustment documentation/ reporting capabilities, as well as driving continuous improvement efforts. Will be responsible for professional coaching and mentoring of program team members

Responsibilities and Qualifications

Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.

Lead the day-to-day execution of Strategic Risk Adjustment Program engagements taking ownership of the engagement deliverables, outcomes and communication of both

Ensure high-quality encounter submissions: Use CMS response files, vendor reports, and internal claims data to determine the source of submission or adjudication errors

Use data to refine Risk Adjustment strategy: Assess our Risk Adjustment programs by reviewing year-over-year risk condition persistence and the impact of supplemental activities. Modify and refine Risk Adjustment strategy based on findings.

Ensure regulatory compliance by reviewing all CMS or HHS guidance and regulations around Risk Adjustment, encounter submission and related topics. Monitor and track that impact is identified, any changes needed are performed and all internal processes documentation is updated to ensure strict adherence to regulatory guidelines.

Serve as Subject Matter Expert: Work collaboratively with other departments to ensure Risk Adjustment goals are integrated into CBC operations. Educate departments across the organization about how their activities impact risk adjustment.

Work proactively with vendors: Monitor and guide external vendor partners to ensure program goals are being met

Evaluate risks to risk adjustment programs goals and objectives and escalate as appropriate.

Conduct periodic market review to understand industry leading practices and drive continuous improvement in department approaches, methods, and tools and organizational awareness of department capabilities.

Create and conduct risk adjustment training for new hires, exiting direct reports, departmental staff and other CBC stakeholders across the enterprise to improve performance, quality and team efficiency.

Skills:

Excellent Interpersonal and Communication Skills, facilitating effective collaboration across teams and with external partners, and adept at presenting complex data to non-technical audiences.

Strong Project Management Abilities, managing multiple projects simultaneously to ensure timely and successful completion.

Strategic Vision to align business operations with broader organizational goals.

Business Acumen to drive growth and success through data-driven decisions.

A Member-Centric Mindset, dedicated to delivering exceptional customer experiences and understanding diverse stakeholder needs.

Proactive communication style and ability to work with a variety of stakeholders to achieve project goals.

Knowledge:

Comprehensive, expert level knowledge of CMS and HHS Risk Adjustment regulations

Working knowledge of CMS and HHS Risk Adjustment Payment methodologies and processes

Working knowledge of industry standards and best practices for Risk Adjustment Operations

Experience:

5 years of Operations and/or Program management; to include 3 years of Risk Adjustment Operations or Program Management

1 year staff, team lead or project lead experience

1 years of strategy development

Education, Certification and Licenses:

Bachelor's Degree in Business Administration/Management or Computer and Information Science or 9 years relevant and progressive experience in lieu of Bachelor's degree

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Full Time