Senior Manager, Corporate Compliance - Risk Adjustment
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. As a Senior Manager, Medicare Compliance – Risk Adjustment, you are responsible for overseeing and maintaining compliance with CMS regulations related to Medicare Advantage Risk Adjustment, Hierarchical Condition Categories (HCCs), encounter data submission, documentation and coding compliance, and related regulatory requirements. This position serves as a key compliance leader and subject matter expert, partnering with Risk Adjustment Operations, Coding, Provider Education, Clinical Documentation Improvement (CDI), Internal Audit, Legal, and Government Affairs teams to ensure organizational adherence to CMS requirements. The ideal candidate possesses extensive experience in Medicare Advantage compliance and a deep understanding of CMS Risk Adjustment methodologies, diagnosis coding requirements, medical record documentation standards, RADV audits, and evolving regulatory guidance.
Requirements
- Minimum 7 years of experience in Medicare Advantage, Risk Adjustment, Coding Compliance, Audit, or Regulatory Compliance
- Minimum 5 years in a leadership role
- One or more of the following certifications: CPMA (Certified Professional Medical Auditor), CRC (Certified Risk Adjustment Coder), CPC (Certified Professional Coder), CCS (Certified Coding Specialist)
- Willingness to travel up to 10% (including by plane)
Nice To Haves
- Health Information Management (RHIA/RHIT)
- Nursing – Strong understanding of clinical documentation and medical record review
- Certified Risk Adjustment Coder (CRC) with compliance experience
- Provider coding audit/compliance leadership experience
- Medicare Advantage compliance leadership experience supporting RADV, HCC validation, and CMS audits
Responsibilities
- Lead the Medicare Advantage Risk Adjustment compliance program.
- Monitor and interpret CMS regulations, HPMS memoranda, Final Rules, Medicare Managed Care Manual guidance, RADV requirements, and OIG enforcement activities.
- Assess operational processes for compliance risks related to risk adjustment activities.
- Develop and implement corrective action plans for identified compliance issues.
- Conduct compliance risk assessments related to coding, documentation, and encounter data submissions.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
