Risk Adjustment Program Manager


Risk Adjustment Program Manager is an integral part of a small team whose role is to improve revenue, in order to ensure that Americas Health Plan achieves its mission to provide high quality service to individuals with complex medical needs. Specifically, the Program Manager, Risk Management provides essential administrative and project management support to all functions within the risk adjustment program, which include interaction with all levels of healthcare staff supporting internal and external business and clinical functions. The ideal candidate possesses excellent customer service skills, project management skills, organizational skill, and high attention to detail.

• The Risk Adjustment Program Manager serves as a primary liaison for key departments including Finance, Operations, IT, Business Intelligence/Clinical Analytics, Clinical, Compliance, and Quality.
• The Risk Adjustment Program Manager maintains excellent relationships with vendors and provides ongoing administrative coordinator and project management support to clinical and administrative staff.
• Coordinates risk adjustment program projects. Responsibilities include: following project plans, workflows, and timelines; Coordinating and facilitating meetings of project stakeholders; Tracking and communicating project statuses; and tracking project timeframes and deliverables.
• Understands data and is able to navigate and create report that monitors key performance indicators.
• Ensures the accuracy and timeliness of report and data given to providers by working with key project specialists.
• Be responsible for coordinating the day to day operations of vendors associated with risk assessment projects.
• Assist in the development and rollout of training for both nonclinical and clinical staff – delegated providers, internal providers and external providers as needed.
• Communicates clearly across projects and across many internal and external stakeholders, including, but not limited to: Finance, Operations, IT, Business Intelligence/Clinical Analytics, provider engagement, health homes, Regulatory Affairs and Compliance, Business Planning and Development, affiliated clinical sites, and risk adjustment vendors.
• May work with provider engagement to further program objectives, such as ACAs, HCC capture and proper coding and documentation.
• Responsible for tracking the status of provider projects – such as coordinating the audit of documentation - and facilitating action as needed.
• Develops and implements the annual risk adjustment strategy.
• Keeps up to date on industry trends and writes reports on evolving payment policies.
• Makes informed recommendations to change current business operations, as needed.
• Assists in the development and revision of current procedures and protocols relevant to program activities.
• Identify issues determined to impact risk adjustment, and work with the affected teams to resolve those issues in a manner that complies with all applicable internal and external governing rules and regulations.
• Analyze claims data within the scope of risk adjustment to determine risks or opportunities to the completeness of risk adjustment data.
• Track and report findings of chart audits and opportunities to improve documentation and coding back to providers and staff.
• Support ongoing audit system to assure that improved documentation and coding occurs in a timely manner.
• Assist with the documentation of coding-related departmental policies and procedures, both general and specific to all risk adjusted lines of business.
• Serves as risk adjustment coding subject matter expert for Medicare, Medi-Cal, and health plans, both in day-to-day operations, and on the risk adjustment and encounter data reporting steering committee.
• Evaluates and oversee the development and implementation of CMS and DHCS risk adjustment program changes; incorporate changes and requirements into strategy.
• Uses analytics to define risk adjustment focus. Identify areas to increase quality and maximize opportunities.
• Develops and distributes provider reports for steering committee as it relates to risk adjustment metrics and performance. Develops and implement employee and provider training programs, as needed, to improve risk adjustment performance.


• Bachelor's Degree Preferred
• Minimum of 3 years of experience in Medicare risk adjustment
• Proficient knowledge of risk adjustment programs, data and requirements is preferred.
• Strong problem solving skills with the demonstrated ability to identify research and make decisions based on the day-to-day and vendor problems.
• Ability to think strategically and to understand the underlying business needs.
• The ability to manage multiple priorities, deliver timely and accurate results while ensuring departmental needs are met.
• Proven success in preparing and delivering presentations that convey information critical to the audience and adjusting to meet changing audience needs.
• Ability to listen and understand information and ideas whether presented verbally or written.
• Able to interact easily and appropriately with internal and external individuals with a professional demeanor.
• Experience leading, training, and managing a team with strong organizational skills. Ability to lead cross functional internal teams to execute on complex tasks in a growing and changing environment.
• A minimum of 3 years of medical coding experience.
• Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.
• Excellent organizational, project and program management skills; experience leading change and implementing programs.
• Strong quantitative and analytical skills with the ability to communicate data concisely and clearly to a variety of audiences.
• Demonstrated ability to be an effective, collaborative partner with internal and external stakeholders
• Coding Certificate required: either CPC or CRC from AAPC or CCS from AHIMA. CRC strongly preferred.
• Extensive knowledge of ICD-10-CM coding guidelines.


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