Risk Adjustment Strategic Manager

Elevance Health•Nashville, TN

2d•$102,960 - $185,328•Hybrid

About The Position

The Risk Adjustment Strategic Manager is responsible for overseeing the day-to-day operations and strategic execution of enterprise risk adjustment programs, including prospective and retrospective initiatives, provider engagement and education, data submissions, vendor oversight, and audit readiness. This role serves as a strategic partner to business leadership by driving operational excellence, ensuring compliance with Centers for Medicare & Medicaid Services (CMS) requirements, and supporting initiatives that optimize revenue integrity and program performance.

Requirements

Requires a BA/BS in a related field and minimum of 5 years of experience in a managed care setting with extensive risk adjustment experience with a focus on CMS audit experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Coding knowledge strongly preferred.
MBA or MHA in Healthcare Administration preferred.
Experience working on the payer side of the health insurance industry strongly preferred.
Strong understanding of risk adjustment models, including: Medicare Advantage, Medicaid, ACA Commercial is preferred.
Knowledge of value-based care providers and provider reimbursement models preferred.
Experience working directly with providers and/or provider group leadership strongly preferred.
Preferred background in Clinical Documentation Improvement (CDI) and medical coding practices.
Certified coder credential preferred (e.g., CPC, CRC, CCS, RHIT, RHIA).
Executive-level communication and presentation skills preferred.
Moderate to advanced proficiency in Microsoft Excel, Tableau, or other data reporting and analytical tools preferred.

Responsibilities

Assists management by overseeing day to day operations for risk adjustment programs including both prospective and retrospective, claims, vendor quality, and audits.
Develops metrics, policies, and procedures in support of required deliverables and validation of programs return on investment while ensuring the programs are in compliance with Center for Medicare and Medicaid Services (CMS) program requirements.
Serves as a strategic partner to the business and contributes to ideas and solutions.
Influences others and works effectively to establish and develop working relationships both internally and externally with business stakeholders.
Obtains and complies trend data and educates providers.
Collaborates with the operations risk and compliance teams in implementing and deploying Enterprise Risk and Compliance initiatives, processes, and tools.
Effectively drives remediation of risks and issues by collaborating with Business Operations, Internal Audit and Regulatory Compliance.
Finds root cause and recommends innovative solutions.
Provides oversight and ensures complete and accurate coding for Medical Revenue Management programs driving the revenue we receive from CMS.
Serves as a subject matter expert on coding.
Leads and consults with operations on ad hoc requests/special projects.
Works collaboratively with Enterprise Risk Adjustment team, Business Operations, Regulatory Compliance, and Internal Audit.
Oversee daily operations of risk adjustment programs across prospective and retrospective initiatives.
Provide oversight of provider engagement, provider education, data submissions, vendor quality performance, and audit activities.