Risk Adjustment - Risk Adjustment Program Manager 135-2008

JOB SUMMARY: Responsible for overseeing the day-to-day execution, performance, and optimization of the risk adjustment program across vendor management, medical record retrieval, coding quality, analytics, reporting, and audit readiness. This role drives process improvement, monitors operational and financial performance, ensures compliance with CMS and organizational requirements, and supports retrospective and prospective risk adjustment initiatives.

KEY RESPONSIBILITIES:

• Oversee daily risk adjustment operations and ensure efficient execution across program workflows.
• Identify process gaps and implement improvements across retrieval, coding, reporting, vendor operations, and data workflows.
• Establish, monitor, and manage key performance indicators to track operational performance, RAF performance, coding accuracy, retrieval rates, and vendor outcomes.
• Manage risk adjustment vendors for coding, retrieval, analytics, and prospective programs, ensuring SLA adherence and coding accuracy standards.
• Oversee vendor audits, corrective action plans, and monthly invoice reconciliation against performance and contractual requirements.
• Lead medical record retrieval strategies to improve chart capture rates, reduce turnaround times, and address low-performing provider sites.
• Oversee coding quality assurance processes, including vendor over-reads, internal audits, and compliance with CMS guidelines and organizational policies.
• Coordinate RADV audit readiness activities, including record retrieval, submission tracking, audit response, documentation, and regulatory review preparation.
• Analyze audit results, data issues, and process gaps to identify root causes and implement operational improvements.
• Oversee retrospective chart reviews and prospective engagement programs to support suspect capture, gap closure, new member engagement, and program effectiveness.
• Partner with analytics teams to develop dashboards, reporting, vendor scorecards, ROI analysis, WNRAR reporting, and actionable leadership insights.
• Collaborate cross functionally to resolve issues, improve reporting accuracy, support submissions, and streamline risk adjustment operations.
• Perform other job related duties as required or assigned.

QUALIFICATIONS:

• Strong understanding of Medicare Advantage and ACA risk adjustment models (CMS‑HCC and HHS‑HCC) and RADV analytics.
• Experience managing vendors and holding performance accountability.
• Proven knowledge of CMS guidelines, RADV audits, and coding processes.
• Proven ability to lead cross-functional initiatives and process improvement efforts.
• Experience with reporting tools, dashboards, and data-driven decision-making.
• Excellent written and verbal communication skills, including presenting to senior leadership.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Bachelor's degree in analytics, statistics, health informatics, business, or related field, with a minimum of three (3) years of healthcare analytics, risk adjustment, or population health experience.
• CRC, CPC, or other relevant licenses required.
• Prior experience supporting production planning.
• Prior experience with RAF projections preferred.
• Prior experience with prospective programs and provider engagement models preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin