Program Manager, Risk Adjustment Coding and Quality

Blue Cross Blue Shield of Minnesota•Eagan, MN

1d•Hybrid

About The Position

Blue Cross and Blue Shield of Minnesota is hiring a Program Manager, Risk Adjustment Coding and Quality to design, implement, evaluate, and manage the Risk Adjustment Coding and Quality Program for Medicare, Medicaid, ACA, and Commercial populations. The role supports optimization of earned risk-adjusted revenue and serves as a subject matter expert in risk adjustment coding. It partners with leadership, analytics, providers, vendors, and cross-functional stakeholders to develop strategic initiatives, identify data trends, improve performance, and ensure program strategies and operations meet evolving regulatory, market, provider, and member requirements. The position leads enterprise-wide initiatives, drives delivery within established timelines, and provides leadership and oversight to program management staff. Working closely with the Director, it supports strategic initiative implementation, monitors project progress, and oversees team and vendor performance. The role also leads coding and audit review activities, including medical record reviews, provider and vendor documentation audits, and operational readiness for government risk adjustment audits. The role leads Medicare Advantage and ACA risk adjustment coding operations, including chart review programs, RADV and HRADV audit readiness, and coding validation. It manages and develops certified coding professionals, and partners with providers, vendors, and stakeholders on risk adjustment education, documentation quality, vendor performance, compliance, and audit outcomes. The position is hybrid, with at least two days onsite each week and remote work for the remainder of the week.

Requirements

At least 5 years of progressive project or program management experience.
At least 1 year of staff, team lead, or project lead experience.
Bachelor’s degree, or, in lieu of a degree, an additional two years of relevant experience beyond the listed qualifications.
Ability to communicate expectations and priorities clearly, listen actively to resolve issues and remove barriers, and drive alignment across teams and stakeholders.
Ability to analyze department challenges, guide team decision-making, and collaborate across teams to resolve issues and determine next steps.
Ability to organize team work, balance priorities across projects, and manage time and resources to ensure timely delivery and coordination.
Healthcare or managed care experience.
Experience managing complex projects involving multiple team members, task assignment, internal or external clients, team and customer relationships, and project deliverables.
Experience with data-driven decision-making.
Familiarity with project management tools and Microsoft analytics tools.

Nice To Haves

Strong knowledge of CMS risk adjustment models, including ACA and Medicare Advantage.
Experience with HCC coding, RADV audits, and/or chart review programs.
CPC, CCS, or CRC coding certification.
Experience developing or supporting provider education or training initiatives.
Master’s degree in a related field.
Process improvement experience, such as Lean or Six Sigma.

Responsibilities

Lead Medicare Advantage and ACA risk adjustment coding operations, including chart review programs, RADV and HRADV audit readiness, and coding validation activities.
Manage and develop a team of certified coding professionals, providing leadership, oversight, and coaching to drive coding accuracy, quality performance, and operational excellence.
Partner with providers, vendors, and cross-functional stakeholders to deliver risk adjustment education, ensure vendor performance and compliance, and improve documentation quality and audit outcomes.
Drive development and documentation of initiative designs, requirements, and implementation plans aligned with strategic priorities.
Build relationships with internal and external resources and ensure market, member, and provider considerations are incorporated into program design.
Drive business decision-making to ensure capabilities, systems, and processes meet market expectations, and evaluate alternative approaches.
Manage ongoing program work, recommend strategies and solutions, and influence others to execute strategies across complex programs.
Select appropriate metrics and ensure measurement, data analysis, and evaluation for initiatives.
Develop and update program or project plans, timelines, and deliverables while coordinating multiple subprocesses.
Develop and implement communication plans with leadership, including status and progress updates.
Stay informed about changes in healthcare markets and regulatory or quality-measurement programs.
Support strategic initiatives, monitor project progress, and oversee team and vendor performance.
Lead coding and audit review activities, medical record reviews, documentation audits, and operational readiness for government audits.
Perform additional responsibilities consistent with the scope and level of the role, as assigned.