Lead, Medicare & ACA Risk Adjustment

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); On-site; USD 104,000 - 127,000; Full time

Benefits offered by this job

PTO

Medical/dental/vision insurance

401(k)

Well-being benefits

Variable pay

Job summary

Blue Cross Blue Shield of Massachusetts is seeking a Manager of Medicare & Commercial Risk Adjustment in Hingham, MA. You will lead a team of certified coders and QA auditors, overseeing MA and ACA risk adjustment coding and medical record reviews for CMS and HHS submissions.

The role drives quality, compliance, and process improvements across internal and external partners. You will build provider relationships, deliver ongoing education on risk adjustment, and ensure audit readiness with

Qualifications

• Five or more years in Risk Adjustment Coding with CMS-HCC and ACA models.
• Managed or supervised coding teams and QA processes.
• Active CRC certification; CPC or CCS accepted in lieu of CRC.
• Strong knowledge of ICD-10-CM and CMS/HHS risk adjustment methodologies.

Responsibilities

• Lead and develop a team of certified professional coders and QA auditors.
• Oversee internal and external coding partners to ensure quality and compliance.
• Ensure accurate diagnosis coding for MA and ACA risk adjustment models.
• Validate medical record reviews to align documentation with submissions.
• Implement QA programs to monitor coding accuracy and compliance.
• Support audit readiness activities across CMS-RADV and HHS-RADV.
• Educate providers and internal stakeholders on risk adjustment documentation and coding.
• Build relationships with providers to promote compliant documentation.
• Stay current with CMS-RADV and HHS-RADV requirements.

Skills

Risk adjustment coding

Leadership

CMS knowledge

CMS-RADV

CMS-HCC

Education

Bachelor's degree or equivalent

Tools

NLP AI coding

Job description

Blue Cross Blue Shield of Massachusetts is seeking a Manager of Medicare & Commercial Risk Adjustment in Hingham, MA. You will lead a team of certified coders and QA auditors, overseeing MA and ACA risk adjustment coding and medical record reviews for CMS and HHS submissions.

The role drives quality, compliance, and process improvements across internal and external partners. You will build provider relationships, deliver ongoing education on risk adjustment, and ensure audit readiness with