Risk Adjustment Program Manager

Job Title: Risk Adjustment Program Manager

Reports To: Vice President, MyTruAdvantage

The primary responsibility of the Risk Adjustment Program Manager is to serve as the subject matter expert for risk adjustment, maintaining oversight of all risk adjustment activities. This role will support Medicare Advantage and ACA risk adjustment programs.

Brief Description of Duties:

Serve as the expert on Medicare Risk Adjustment models; monitor regulatory changes, ensuring adherence to CMS/HHS guidelines

Develop and monitor metrics and KPIs to track the success of solutions and improvements; develop dashboards to share risk adjustment trends to key stakeholders; communicate risk adjustment impacts across all levels of the company

Conduct comprehensive research and analysis to identify trends and areas of opportunity related to risk adjustment; contribute to the development and implementation of strategic initiatives and a risk adjustment work plan; collaborate with plan partners to leverage a lean team and all possible resources to improve risk adjustment outcomes

Responsible for forecasting revenue and collaborating with finance team

Create and maintain department policies and procedures

Ensure plan readiness and compliance for RAD-V and CMS audits

Own vendor oversight of data integration and coding accuracy for Encounter Data Submissions and risk analytics

Minimum Skills Requirement:

Minimum of 5 years of experience in Medicare risk adjustment

Strong knowledge of CMS risk adjustment models/methodologies and HCC coding

Strong analytical, organizational, problem-solving, vendor management, and critical thinking skills

Ability to work independently and manage multiple projects involving cross-functional teams and external vendors

Ability to interpret and analyze complex data and translate this into meaningful, actionable information

High standards of quality and accuracy

Advanced skills in Microsoft Excel

Commitment to maintaining confidentiality in compliance with HIPAA

All positions are subject to change based on the needs of the business