Manager, Risk Adjustment Quality Assurance

Millennium Physician Group•New York, NY

20h

About The Position

The Manager of Burden of Illness Quality Assurance oversees the prospective, concurrent, and retrospective risk adjustment internal audit and education functions. This role provides strategic and operational leadership for teams responsible for auditing HCC capture, clinical validation, and documentation compliance across the full risk adjustment lifecycle. The Manager ensures consistent audit methodology, regulatory compliance, staff development, and performance improvement, while serving as a subject-matter leader for CMS and HHS risk adjustment models.

Requirements

Bachelor’s degree or equivalent work experience
Active credential: CRC, CPC, CPMA, or similar certification
5+ years of risk adjustment coding and/or auditing experience
Strong knowledge of CMS-HCC models, ICD-10-CM, MEAT, and audit methodology
Experience providing education or training to internal coding teams
Excellent written and verbal communication skills
Strong analytical and reporting skills
Ability to work independently in a fast-paced, cross-functional environment
Regulatory and compliance expertise
Attention to detail and critical thinking
Professional communication and presentation skills
Ability to translate complex coding rules into practical guidance
Collaborative, consultative approach

Responsibilities

Directly manage and develop internal auditors and educators supporting prospective, concurrent, and retrospective risk adjustment workflows.
Establish standardized audit frameworks, scoring methodologies, and inter-rater reliability processes across all review types.
Set performance expectations, conduct evaluations, and implement competency and career development plans.
Lead hiring, onboarding, training, and succession planning for audit and education staff.
Oversee prospective chart scrub audits, concurrent HCC validation and gap capture audits, and retrospective rejection/validation audits.
Ensure audits align with CMS risk adjustment regulations, ICD-10-CM Official Guidelines, and organizational compliance standards.
Develop and maintain audit policies, procedures, and quality assurance programs.
Establish KPIs and dashboards for prospective, concurrent, and retrospective audit programs.
Analyze trends in missed HCCs, unsupported diagnoses, rejection rates, and documentation gaps.
Drive continuous improvement initiatives to enhance accuracy, completeness, and financial integrity.