Manager, Risk Adjustment Operations

Capital Blue Cross•Susquehanna Township, PA

2d•$86,710 - $161,040

About The Position

The Manager, Risk Adjustment Operations provides end-to-end operational management, delivery and support to new and existing MA and ACA Risk Adjustment Programs. Working closely with the Director, Risk Adjustment Programs, this position drives execution of operational priorities, manages program performance, and ensures timely delivery of strategic initiatives through data-driven decision making, cross-functional coordination, and operational accountability. The manager will be responsible for professional coaching and mentoring of program team members while fostering continuous process improvement.

Requirements

Strong verbal and written communication skills, including the ability to communicate complex operational issues clearly to business partners and leadership.
Strong organizational and project management skills, with demonstrated ability to manage multiple priorities, deadlines, dependencies, and deliverables.
Ability to lead cross-functional initiatives and build effective working relationships across internal departments and external vendor partners.
Strong analytical and problem-solving skills, including demonstrated ability to interpret dashboards, key performance indicators, and operational reporting to monitor performance, identify risks, and drive operational decision-making.
Strong business acumen, including the ability to understand operational, financial, contractual, and regulatory considerations.
Ability to proactively identify risks, remove barriers, develop mitigation plans, and escalate issues appropriately.
Strong vendor management skills, including experience in supporting vendor evaluation, onboarding, implementation, performance monitoring, and transitions.
Ability to work independently, exercise sound judgement, and drive accountability in a fast-paced, deadline-oriented environment.
Proficiency with Microsoft Office applications, including advanced Excel skills; ability to interpret and leverage Power BI or other business intelligence reporting preferred.
Working knowledge of Medicare Advantage and ACA Risk Adjustment regulations and payment methodologies.
Working knowledge of industry standards and best practices for Risk Adjustment operations.
Working knowledge of cross-functional Risk Adjustment operational processes, including provider engagement, analytics, coding, vendor management, and regulatory compliance.
5 years of Operations and/or Program management.
3 years of Risk Adjustment Operations or Program Management.
Experience leading complex, cross-functional operational initiatives involving multiple stakeholders and competing priorities.
Experience supporting vendor selection, RFP processes, business requirements, Statement of Work (SOWs), implementation, onboarding, and ongoing vendor performance management.
Experience monitoring operational performance and driving execution to meet regulatory deadlines and business objectives.
1 year staff, team lead or project lead experience.

Nice To Haves

Experience supervising staff and provider operational leadership across cross-functional programs or initiatives preferred.
Lean Six Sigma or other operational excellence/process improvement certification preferred.

Responsibilities

Drive day-to-day operational execution of Medicare Advantage and ACA Risk Adjustment initiatives, ensuring project milestones, regulatory deadlines, and operational deliverables are completed on schedule.
Develop and maintain integrated project plans, operational calendars, risk logs, and status reporting to support successful program execution.
Monitor program performance through dashboards, KPIs, and operational metrics; identify trends, escalate risks, and recommend data-driven improvements.
Coordinate cross-functional activities across Analytics, Coding, Provider Engagement, Chart Retrieval, Actuarial, Compliance and vendor partners to ensure successful execution of operational priorities.
Hold internal teams and external vendors accountable for operational performance, deliverables, timelines, service level expectations, and issue resolution.
Proactively identify operational barriers and develop mitigation plans to minimize impact to program performance.
Lead operational vendor onboarding and offboarding activities, support vendor evaluations and RFP processes, and partner with procurement and other stakeholders to ensure successful implementation and ongoing operational performance.