Risk Adjustment Compliance Project Manager

Medica•St. Louis, MO

1d•$70,200 - $120,400•Hybrid

About The Position

The Risk Adjustment Compliance Project Manager is responsible for leading compliance focused initiatives that ensure the accuracy, integrity, and regulatory adherence of Medica’s Risk Adjustment programs across Medicare Advantage, Medicaid, and ACA lines of business. This role provides subject matter expertise in regulatory requirements, audit readiness, and governance, and serves as a cross functional project leader for compliance, audit, and documentation initiatives. The Risk Adjustment Compliance Project Manager plays a critical role in maintaining audit readiness, mitigating compliance risk, and ensuring risk adjustment policies, procedures, and provider education aligning with CMS and state regulations.

Requirements

Bachelor’s degree in Healthcare Administration, Business, Health Information Management, Compliance, or related field
5+ years of experience in healthcare operations, risk adjustment, healthcare compliance and/or audit, or regulatory support
Demonstrated experience supporting regulatory and operational audits, with a strong understanding of Risk Adjustment programs and applicable CMS and state regulatory requirements
Proven ability to lead compliance‑focused initiatives through effective project management, organization, and analytical skills
Excellent written and verbal communication skills, with the ability to collaborate across cross‑functional teams and communicate complex regulatory requirements clearly to both technical and non‑technical stakeholders
Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

Nice To Haves

Experience supporting RADV or CMS or DHS compliance audits
Background in provider education, clinical documentation, or coding compliance
Experience developing and maintaining healthcare policies and procedures
Experience supporting Medicare Advantage, Medicaid, or ACA risk adjustment programs

Responsibilities

Coordinate and support internal and external audits, including RADV and other regulatory or operational reviews
Serve as the primary point of coordination for audit requests, documentation retrieval, validation, and submission
Track audit findings and collaborate with stakeholders on corrective action plans and remediation efforts
Support ongoing audit readiness by strengthening controls, workflows, and documentation standards
Develop, maintain, and update Risk Adjustment policies, procedures, and standard operating documentation
Ensure documentation reflects current regulatory guidance, operational practice, and internal control requirements
Partner with Compliance and Operational leaders to ensure consistent application and understanding of policies
Maintain audit‑ready documentation, including version control and governance standards
Lead Risk Adjustment compliance initiatives to ensure adherence to CMS and state regulatory requirements
Interpret and operationalize regulatory guidance impacting risk adjustment documentation, submission, and oversight
Partner closely with Compliance, Quality, Legal, and Risk Adjustment Operations to align compliance activities with enterprise standards
Identify compliance risks, gaps, and trends, and drive mitigation strategies to reduce regulatory exposure
Collaborate with Provider Engagement and Quality teams to support provider education related to compliant documentation and risk adjustment standards
Ensure provider education materials align with regulatory requirements and Medica compliance expectations
Act as a subject matter expert for documentation and compliance‑related questions impacting providers and internal teams
Lead compliance‑driven risk adjustment projects from planning through execution
Coordinate cross‑functional efforts to implement regulatory changes or compliance improvements
Identify and implement process improvements that strengthen program integrity and operational effectiveness
Provide compliance status updates and reporting to leadership as needed