Job Title: Risk Adjustment Manager
Location: Remote/Hybrid
Job Type: Full-Time
Department: Medicare Risk Adjustment
Reporting to: Director of Medicare Risk Adjustment

Company Overview:
CSTS/Ultimate Health Plans is a leading provider of healthcare solutions, dedicated to ensuring the well-being of our members through innovative programs and personalized care. We are committed to excellence in Medicare Risk Adjustment (MRA) operations and are seeking a highly skilled Risk Adjustment Manager to join our dynamic team.

Position Overview:
As a Risk Adjustment Manager, you will play a pivotal role in overseeing and enhancing our Medicare Risk Adjustment operations. Your primary responsibility will be to ensure the accuracy and efficiency of our Hierarchical Condition Category (HCC) coding processes, while also supporting health plan operations through strategic auditing projects and educational initiatives.

Key Responsibilities:

• Lead and manage auditing projects focused on HCC coding accuracy and compliance with regulations.
• Extract and distribute MRA reports to contracted Independent Physician Associations (IPAs).
• Serve as a primary point of contact for HCC and risk adjustment inquiries, providing accurate information and support to stakeholders.
• Coordinate procedures to obtain necessary medical records that support MRA efforts, in collaboration with the physician relations department.
• Create and deliver presentations for Joint Operating Committee (JOC) meetings, reporting on departmental activities and performance metrics.
• Provide comprehensive updates during monthly JOC meetings with IPAs, ensuring alignment on MRA objectives.
• Participate in industry meetings to stay updated on regulatory changes and standards.
• Manage initiatives aimed at correcting errors in MRA submissions and handling claims issues.
• Facilitate the processing of changes to HCC codes based on CMS guidelines.
• Collaborate in creating and updating educational content for healthcare providers.
• Assist in maintaining and revising coding guidelines to align with industry best practices.
• Provide training and mentorship to MRA team members, including HCC Coders and Provider Educators.

Qualifications:

• Bachelor’s degree in health administration, Public Health, or related field.
• CPC: Certified Professional Coder, CRC: Certified Risk Coder required.
• Minimum of 5 years of experience in risk adjustment, HCC coding, or a related field.
• Proven ability to manage complex projects and multiple priorities in a dynamic environment.
• Strong communication and presentation skills.
• Proficiency in data management systems, particularly QA Prima.
• Deep understanding of medical coding systems, especially HCC and MRA methodologies.

Benefits:

• Competitive salary and comprehensive benefits package.
• Opportunities for professional development and advancement.
• Supportive and innovative work environment.

Job Type: Full-time

Pay: $47,800.00 - $52,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Education:

• Bachelor's (Required)

Experience:

• risk adjustment, HCC coding, or a related field: 5 years (Required)
• data management systems, particularly QA Prima.: 1 year (Preferred)

License/Certification:

• Certified Professional (CPC) or Certified Risk Coder (CRC) (Required)

Work Location: Hybrid remote in Spring Hill, FL 34609