Manager, Risk Adjustment and 5-Stars

JOB TITLE: Sr. Manager, Risk Adjustment

DEPARTMENT: Quality Improvement and Risk Adjustment

REPORTS TO: Sr. Director, Quality Improvement, Risk Adjustment, and Health Analytics

JOB SUMMARY: The Sr. Risk Adjustment Manager is responsible for leading and optimizing risk adjustment operations across all lines of business and entities, including Medicare Advantage, Marketplace, and other affiliated health plans, medical groups, and MSO functions. This role serves as a subject matter expert on federal risk adjustment regulations, policies, and methodologies. The position involves close collaboration with internal teams, providers, and external partners to improve risk score accuracy, provider engagement, and regulatory compliance. The Sr. Manager will also lead the development and operationalization of reporting tools, analytics, and workflows to support risk adjustment performance and data integrity across programs. This role plays a key part in aligning cross-functional teams, driving RADV audit readiness, and informing enterprise-level decisions related to financial forecasting, coding accuracy, and population health.

ESSENTIAL JOB FUNCTIONS:

• Lead Risk Adjustment Strategy & Operations: Oversee the development, implementation, and continuous improvement of risk adjustment programs across all lines of business, including Medicare Advantage (CMS-HCC), Marketplace (HHS-HCC), and RxHCC models, ensuring regulatory compliance, coding accuracy, and risk score optimization.
• Stay Current on Model Versions & Methodologies: Maintain deep expertise in CMS-HCC model updates (e.g., V24 vs. V28), RxHCC methodology for Medicare Part D, and HHS-HCC annual model recalibrations, including normalization factors, coding intensity adjustments, and future model transitions as released in CMS Advance Notices and Final Rate Announcements.
• Manage Department Staff & Cross-Functional Teams: Provide strategic direction and oversight for Risk Adjustment and coding department staff. Assemble and lead cross-functional and ad hoc teams for specific initiatives such as RADV audit readiness, encounter accuracy improvement, and provider education.
• Build and Manage Risk Adjustment Reporting & BI Tools: Design, implement, and maintain dashboards and reporting tools to monitor performance metrics such as risk score trends, gap closure rates, encounter completeness, RxHCC attribution, and audit readiness benchmarks.
• Conduct Data Gap Analysis & Targeted Program Design: Perform thorough analyses to identify documentation, coding, and encounter data gaps. Use findings to develop targeted retrospective and prospective strategies to improve risk capture and data completeness, especially in hard-to-reach or low-utilization populations.
• Provider and Vendor Collaboration: Partner with provider groups, ACOs, MSOs, and vendors to ensure alignment with risk adjustment documentation and coding guidelines. Design and monitor clinical documentation improvement (CDI) initiatives to capture accurate and complete conditions, including RxHCC-relevant conditions.

EDUCATION/EXPERIENCE:

• Bachelor’s degree required; equivalent combination of education and relevant experience may be considered in lieu of a degree
• Minimum 5–7 years of progressive experience in Risk Adjustment, with hands-on expertise in CMS-HCC and HHS-HCC program operations, coding, analytics, and regulatory compliance
• At least 3 years of supervisory or managerial experience, preferably leading cross-functional teams and/or vendor management in a health plan or provider organization
• Strong working knowledge of Medicare Advantage (CMS-HCC) and Marketplace (HHS-HCC) risk adjustment regulations, encounter data submission requirements, and model methodologies
• Experience with RxHCC risk models and PDE submission processes preferred
• Familiarity with RADV audits, HHS IVA audits, and CMS data submission protocols (e.g., RAPS, EDPS, EDGE)