Medicare Risk Adjustment Manager

KHS reasonably expects to pay starting compensation for the position of Medicare Risk Adjustment Manager in the range of $104,899 - 133,746 Salary.

*On-Site Position*


About us

Kern Health Systems (KHS) is dedicated to improving the health status of our members through an integrated managed health care delivery system.

CMS, Risk Adjustment, HCC, Medicare, Healthcare, Manager, Supervisor, Special needs, NCQA, Regulatory Requirements, Reporting, Evaluation, Compliance. 

About the role

Under general direction of Senior Director of Delegation Oversight, the Risk Adjustment Manager is responsible for overseeing and managing the risk adjustment program for the Dual Special Needs Plan (D-SNP) line of business for KHS. This position will ensure that the organization remains compliant with risk adjustment activities including activities delegated to subcontracted entities, in line with the Department of Health Care Services contract, NCQA standards, regulatory requirements enforced by the DHCS, Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and any other applicable guidelines. The role involves managing data collection, coding accuracy, compliance, reporting, evaluation and oversight of delegated functions, collaboration across multiple teams, including clinical, IT, data analytics, claims, and compliance, to optimize risk adjustment processes, reduce discrepancies, and drive improvements in financial and operational performance.

Essential Duties and Responsibilities

• Develop and oversee delivery of risk adjustment strategies training program to educate the provider network of best practices for coding and risk adjustment activities.
• Oversee the entire risk adjustment program and ensure compliance with CMS guidelines, including ICD-10 coding, risk scores, and program integrity.
• Ensure delegated entities monitor and audit medical records and coding accuracy including HCC and ICD-10 codes, to minimize risk of audits and penalties.
• In collaboration with delegated entities, utilize analytics to track trends, identify gaps in documentation, and drive proactive initiatives to optimize coding accuracy and risk scores.
• Identify and implement process improvements to enhance operational efficiency, reduce risk exposure, and ensure timely and accurate risk adjustment submissions.
• Coordinate, conduct, and document delegation assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
• Review policies and procedures to ensure delegated entities and subcontractors comply with state, federal, NCQA, and any other applicable requirements.
• Prepares status reports from delegated entities. Develops corrective action plans when deficiencies are identified, and documents follow-up to completion. Ensures compliance with reporting requirements by tracking the receipt and completeness of reports.
• Coordinate with other internal departments to ensure delegated entities and subcontractors are fulfilling and following contractual and regulatory obligations.
• Coordinate and conduct annual oversight audits of all delegated entities.
• Collect and review data from internal departments to ensure consistency with the purview of the delegated entity.
• Prepare reports for executive review and approval. 
• Possess working knowledge of KHS Policies and Procedures.
• Assists management staff in completing Delegation and Oversight Departmental related projects as assigned.
• Interfaces with other departments in the development, preparation and distribution of required reports.
• Performs other job-related duties as assigned.
• Travel independently to conduct delegation oversight with own reliable transportation.
• Adheres to all company policies and procedures relative to employment and job responsibilities.
  
  

CMS, Risk Adjustment, HCC, Medicare, Healthcare, Manager, Supervisor, Special needs, NCQA, Regulatory Requirements, Reporting, Evaluation, Compliance. 

Employment Standards

Education and experience:

Bachelor's degree in Business or Healthcare Administration from an accredited school; AND Four (4) years’ experience in risk adjustment management or a related role in a healthcare organization.

OR

Eight (8) years’ experience in risk adjustment management or a related role in a healthcare organization.

• Strong understanding of CMS risk adjustment including HCC model.
• Experience with data analytics, medical coding, and auditing.
• Relevant certifications (CPC, CRC, CCS) preferred.
  
  

Knowledge: 

• CMS regulations
• Auditing processes
• Creation and implementation of a risk adjustment strategy
• Microsoft Office Suite and experience with risk adjustment software platforms
  
  

Ability to:  Communicate effectively, both verbally and in writing, with internal and external stakeholders; adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities with a high level of attention to detail; identify challenges and develop strategies to address; prioritize workload; make decisions; prepare and organize data analytics regarding risk adjustment and create an action plan to enhance performance.

Other:  Required travel up to 40%. Possession of valid California Driver’s License and proof of valid State required auto liability insurance.

CMS, Risk Adjustment, HCC, Medicare, Healthcare, Manager, Supervisor, Special needs, NCQA, Regulatory Requirements, Reporting, Evaluation, Compliance.