Risk Adjustment Manager
Position Summary The Risk Adjustment Manager is responsible for designing, executing, and continuously improving the organization’s Medicare and Medicare Advantage risk adjustment strategy. This role ensures accurate, compliant capture of patient acuity while driving provider engagement, operational excellence, and financial performance across employed and affiliate clinics. This is a strategy + execution role, bridging clinical operations, analytics, providers, coding teams, and health plan partners. Position may be remote with some travel required.
Key Responsibilities
Risk Adjustment Strategy & Performance Own the end-to-end implementation of Medicare and Medicare Advantage risk adjustment strategy, including prospective, concurrent, and retrospective models Establish annual RAF targets, forecasts, and performance monitoring cadence Translate CMS HCC guidance into actionable clinical and coding workflows Monitor coding intensity, suspect capture rates, and year-over-year RAF trends Provider Enablement & Engagement Partner with providers to improve documentation accuracy and chronic condition capture Lead provider education on risk adjustment, HCCs, and compliant documentation practices Collaborate with Provider Relations and Clinical Leadership to embed workflows into daily practice Support employed and affiliate clinics with tailored engagement strategies Operational Oversight Oversee coding workflows across internal and offshore teams Ensure quality assurance processes are in place for coding accuracy and compliance Coordinate chart review programs, vendor partnerships, and audit readiness Maintain CMS compliance and audit-defensible documentation standards Data, Analytics & Reporting Partner with analytics teams to develop RAF dashboards and performance reporting Interpret claims, encounter, and EMR data to identify gaps and opportunities Provide regular performance updates to executive leadership Support payer reporting and reconciliation efforts Cross-Functional Leadership Serve as the risk adjustment subject matter expert across the organization Collaborate with Quality, Care Management, Finance, and IT teams Support contract strategy and value-based care financial modeling Drive continuous improvement initiatives and best-practice standardization Experience Required Bachelor’s degree (clinical background preferred) 5+ years of experience in Medicare and Medicare Advantage risk adjustment Strong working knowledge of CMS HCC models and documentation guidelines Experience supporting provider education and clinical workflow optimization Proven ability to manage distributed or offshore coding teams Strong analytical, communication, and stakeholder management skills US-based with availability to support provider and leadership engagement Preferred CRC, CPC, CCS, RN, or equivalent credential Experience in value-based care, ACOs, or delegated risk arrangements Experience with Revenue Cycle Management Experience supporting both employed and affiliate provider networks Familiarity with RAF forecasting and financial impact modeling Apply To This Job