Sr Mgr, Quality Risk Adjustment (Health plan/MCO experienced)

CareSource•Dayton, OH

2d•$113,000 - $197,700

About The Position

Job Summary: The Senior Manager, Quality Risk Adjustment is responsible for overseeing the Quality Risk Adjustment (QRA) Medical Record Review (MRR) program which includes chart retrieval and coding while ensuring compliance with regulatory standards and optimizing quality outcomes. This role will also involve leveraging artificial intelligence (AI) technologies to enhance data accuracy, improve efficiency, and overall quality in the chart review program. Essential Functions: Lead and manage the MRR Team, providing guidance, training, and support to ensure high-quality performance in medical record retrieval and coding. Develop and implement strategic plans to optimize risk adjustment processes and improve overall quality metrics for insourced and outsourced activities MRR. Manage outsourced vendors to execute to operational production plan goals and contractual requirements. Manage vendor administrative expenses including chart copying costs. Work with QRA Compliance Team to establish and maintain MRR quality assurance protocols for medical record retrieval and coding to ensure compliance with all applicable regulations and industry standards. Conduct regular audits and assessments of MRR team’s work for documentation retrieval accuracy, completeness, and efficiencies. Research technological solutions such as the use of artificial intelligence (AI), natural language processing (NLP), workflow management tools, and more to enable more efficient and accurate data collection and reporting of risk adjustment data, ensuring accuracy and timeliness. Collaborate with Data Science, Sourcing, IT, and all necessary stakeholders to deploy AI/NLP solutions. Collaborate with QRA teams, market provider relations teams, providing transparency and timely escalations as needed to ensure operational goals are achieved. Improve insourced retrieval and outsourced vendor workflows and enhance the integration of AI tools in risk adjustment initiatives. Develop and implement training programs for staff on how to most efficiently and effectively retrieve medical records, vendor management principles, and the use of AI tools. Identify opportunities for process improvements and implement initiatives to enhance operational efficiency and quality outcomes. Monitor key performance indicators (KPIs) related to risk adjustment and quality metrics, reporting findings to senior leadership. Engage with business stakeholders to gather, analyze, and clearly articulate business requirements for AI solution development or procurement. Assess organizational needs and recommend whether to build in-house AI tools or buy commercial AI solutions based on business goals and technical feasibility. Translate complex business objectives into detailed technical specifications for AI projects, ensuring alignment with business strategies. Leverage hands-on experience in risk adjustment to guide the design, implementation, and optimization of AI models relevant to risk scoring and analytics. Collaborate with cross-functional teams—including data science, IT, and compliance—to ensure AI solutions meet regulatory and industry standards for risk adjustment. Evaluate, monitor, and communicate the performance and impact of AI solutions on risk adjustment processes and outcomes. Perform any other job related duties as requested.

Requirements

Bachelor's degree in Health Administration, Healthcare Management, or a related field is required
Equivalent years of relevant work experience may be accepted in lieu of required education
Seven (7) years experience in risk adjustment medical record review program management, medical coding, or quality management in a healthcare setting required
Three (3) years of leadership experience required
Two (2) years experience with implementation and/or development of AI solutions in a heathcare setting required
Knowledge of ICD-10 Coding
Knowledge of HCC Risk Adjustment models
Knowledge of CMS regulatory guidelines
Ability to utilize AI Technologies and their applications in healthcare data management and analysis
Excellent leadership, communication and interpersonal skills
Strong data analytical and problem-solving skills
Familiarity with CMS and HHS RADV audits
Skilled in vendor management, oversight and performance reporting

Nice To Haves

Master's degree is preferred
AAPC CPC (Certified Professional Coder), CRC (Certified Risk Adjustment Coder), AHIMA RHIT, or equivalent preferred

Responsibilities

Lead and manage the MRR Team, providing guidance, training, and support to ensure high-quality performance in medical record retrieval and coding.
Develop and implement strategic plans to optimize risk adjustment processes and improve overall quality metrics for insourced and outsourced activities MRR.
Manage outsourced vendors to execute to operational production plan goals and contractual requirements.
Manage vendor administrative expenses including chart copying costs.
Work with QRA Compliance Team to establish and maintain MRR quality assurance protocols for medical record retrieval and coding to ensure compliance with all applicable regulations and industry standards.
Conduct regular audits and assessments of MRR team’s work for documentation retrieval accuracy, completeness, and efficiencies.
Research technological solutions such as the use of artificial intelligence (AI), natural language processing (NLP), workflow management tools, and more to enable more efficient and accurate data collection and reporting of risk adjustment data, ensuring accuracy and timeliness.
Collaborate with Data Science, Sourcing, IT, and all necessary stakeholders to deploy AI/NLP solutions.
Collaborate with QRA teams, market provider relations teams, providing transparency and timely escalations as needed to ensure operational goals are achieved.
Improve insourced retrieval and outsourced vendor workflows and enhance the integration of AI tools in risk adjustment initiatives.
Develop and implement training programs for staff on how to most efficiently and effectively retrieve medical records, vendor management principles, and the use of AI tools.
Identify opportunities for process improvements and implement initiatives to enhance operational efficiency and quality outcomes.
Monitor key performance indicators (KPIs) related to risk adjustment and quality metrics, reporting findings to senior leadership.
Engage with business stakeholders to gather, analyze, and clearly articulate business requirements for AI solution development or procurement.
Assess organizational needs and recommend whether to build in-house AI tools or buy commercial AI solutions based on business goals and technical feasibility.
Translate complex business objectives into detailed technical specifications for AI projects, ensuring alignment with business strategies.
Leverage hands-on experience in risk adjustment to guide the design, implementation, and optimization of AI models relevant to risk scoring and analytics.
Collaborate with cross-functional teams—including data science, IT, and compliance—to ensure AI solutions meet regulatory and industry standards for risk adjustment.
Evaluate, monitor, and communicate the performance and impact of AI solutions on risk adjustment processes and outcomes.
Perform any other job related duties as requested.