The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
We are currently hiring a Risk Adjustment Manager to join our team!
What You Will Be Doing:
The Manager of Risk Adjustment is responsible for overseeing and maintaining organizational activities that impact the Risk Adjustment program, including the development and execution of a comprehensive, efficient, and compliant documentation integrity strategy.
Supervises
- Revenue Analyst
- Quality and Risk Adjustment Coder
- Contracted vendors
Our Vision:
Continuously improve the health of our community.
Our Mission:
We provide healthcare value and advance wellness through community partnerships.
Essential Functions:
- Design, lead, and oversee the Risk Adjustment Program, ensuring data integrity, accurate member risk scoring, and appropriate risk-based reimbursement, while maintaining full compliance with applicable program requirements.
- Serve as the Subject Matter Expert (SME) for all aspects of the Risk Adjustment Program, including monitoring regulatory changes and reporting requirements, and ensuring timely communication of updates to relevant internal and external stakeholders.
- Establish and maintain processes to monitor CMS transactions and reconciliation files, ensuring timely and accurate submissions of encounter data and diagnoses.
- Investigate and resolve submission rejections or errors in partnership with internal teams and vendors.
- Monitor ongoing chart review and clinical data validation, including retrospective and prospective review programs that ensure complete and accurate member risk scores in alignment with compliance requirements.
- Analyze performance trends to identify opportunities for improvement, facilitate collaborative discussions with internal and external stakeholders, and guide the development and execution of strategies that enhance program efficiency, effectiveness, and outcomes.
- Develop and manage analytical and predictive modeling tools to identify care gaps and oversee programs with the goal of accurately capturing member risk scores and supporting broader organizational objectives.
- Provide ongoing reporting to leadership on risk adjustment data, risk scores, and risk payments.
- Lead the development of a Risk Adjustment Training Program tailored to operational teams such as care management (CM), utilization management (UM), provider relations, and quality. Ensure organization-wide understanding of risk adjustment principles and how individual roles contribute.
- Provide and/or designate individuals to provide RA training to key stakeholders.
- Oversee the creation and maintenance of policies and procedures to document the RA program design, data flows, audit readiness protocols, and compliance activities. Certify the accuracy and integrity of the data submitted to CMS.
- Develop and manage the RA program budget, ensuring strategic investments in tools, staff, and vendors to optimize program performance.
- Support annual bid development by providing insight into projected risk scores, member stratification, and performance trends that inform benefit design and financial modeling.
- Develop a risk adjustment analytics strategy, including member risk score forecasting, gap identification, and development of insights to inform and support organizational strategies.
- Lead the oversight of delegated entities and vendors ensuring compliance with service-level agreements, CMS technical guidance, and error remediation protocols.
- Serve as the primary liaison for CMS RADV audits and data validation activities, ensuring audit preparedness, data integrity, and timely response to inquiries.
What You Bring:
Knowledge, Skills, Abilities and Competencies
Required
- In depth knowledge of Medicare program and CMS’ Risk Adjustment, Risk Score Program, and data validation
- Project management experience and ability to prioritize tasks and strategies to meet organizational goals and needs.
- Interprets and applies understanding of key financial indicators to inform strategic decisions and drive business performance.
- Manage multiple, complex, and highly visible projects
- Strong analytical skills, including the ability to identify relevant metrics, draw conclusions, and take action based on results.
- Organize people and resources to solve problems and identify opportunities.
- Strong interpersonal skills, including the ability to establish and maintain effective working relationships across all organization levels and with external stakeholders.
- Strong oral and written communication skills, with the ability to convey complex information clearly and professionally to diverse internal and external audiences, and to develop effective workflows, policies, and procedures. Ability to develop and deliver relevant and effective training and supporting materials.
- Ability to handle confidential information with appropriate discretion.
- Ability to speak and be understood in English.
What You Have:
Education and Experience
Required
- Bachelor’s Degree
- Health care experience, preferably with Medicare and Medi-Cal
- Five years’ experience in management role
- Three years’ experience in risk adjustment (HCC) operations and coding
- Project management experience preferred
Licenses, Certifications
Certified Risk Adjustment Coder Certification is preferred.
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision with choices in providers
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.
Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.
Equal employment opportunity, including veterans and individuals with disabilities.
