Manager, Risk Adjustment Program
About The Position
The Manager, Risk Adjustment Program leads a team of Risk Adjustment Coders and oversees contract coding staff. The role conducts internal reviews of provider documentation and coder accuracy to ensure compliance with internal and external standards. It provides performance feedback and audit findings to support leadership in setting benchmarks, acceptable thresholds, and quality assurance programs. The position also oversees projects, process improvements, and vendor performance and outcomes. The manager conducts and oversees coding and documentation audits, provides education and training to clinicians and coders, prepares audit reports for leadership, responds to coding and documentation questions, and collaborates across teams and markets. The role includes hiring and performance management of staff, follow-up reviews after training, and monitoring vendor service-level agreements and statements of work.
Requirements
- Bachelor’s degree or equivalent experience in coding and documentation for Risk Adjustment programs.
- Seven years of related experience, including 3–5 years of professional coding experience.
- Three years of experience in a lead role.
- Experience implementing risk adjustment coding compliance rules and regulations.
- Successful completion of a coding certificate program from an accredited organization; examples include CPC, CRC, or CPMA from AAPC, or CCS or CCS-P from AHIMA.
Responsibilities
- Provide oversight and leadership to internal risk adjustment coders and oversee contract coding staff work product.
- Hire and manage staff performance.
- Perform regular detailed coder audits in accordance with compliance requirements and determine when additional education is needed.
- Conduct internal audits of medical record documentation supporting HCC recapture, AWV/AHA coding, and retrospective coding efforts.
- Pre-audit CMS RADV requests and/or health plan compliance audits to ensure submitted HCC diagnosis codes are supported by medical records.
- Evaluate diagnoses coded from risk adjustment programs and retrospective reviews against coding and documentation guidelines.
- Provide documentation and coding training to clinicians and coders to support compliance with AHA, AMA, CMS, and health plan standards.
- Prepare formal reports of audit results and present them to leadership.
- Respond independently to questions from physicians, practice managers, executive leaders, coders, clinical reviewers, and other risk adjustment staff about billing, coding, and documentation.
- Develop educational programs for coders and/or providers based on audit findings and general coding and documentation rules and regulations.
- Conduct follow-up reviews after initial coder training and determine whether further education is needed.
- Provide additional training identified through follow-up reviews.
- Communicate regularly with senior leadership to ensure necessary information is received promptly.
- Communicate and problem-solve with leaders and peers on coding issues and training requests.
- Work on joint projects with teams such as clinical review and coding education in specific markets.
- Manage and oversee vendor performance for risk adjustment activities and monitor compliance with SLAs and SOWs.
- Perform other assigned responsibilities.
Benefits
- Excellent medical, vision, and dental coverage.
- 401k savings plan with a company match.
- Flexible time off.
- 9 paid holidays.
- Competitive compensation package.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
