Prospective Risk Adjustment Leader

CareFirst BlueCross BlueShield; Reston (VA); Hybrid; USD 105,000 - 195,000; Full time

Benefits offered by this job

Hybrid work arrangement

Job summary

CareFirst BlueCross BlueShield in the greater Baltimore/Washington area seeks a Risk Adjustment Manager to lead prospective risk adjustment strategy across Medicare Advantage, Medicaid and ACA markets. The hybrid role requires collaboration with cross-functional teams and engagement with providers.

You will drive diagnosis capture accuracy, monitor KPIs and guide regulatory and financial forecasting while partnering with senior leadership to advance program objectives and ensure compliant,

Qualifications

• Bachelor's degree required with 5 years in a healthcare payor environment and supervisory/leadership experience.
• Experience leading risk adjustment programs across Medicare Advantage, Medicaid and ACA.
• Certifications in coding (CPC/CRC/CPMA or CCS/CCP) preferred.

Responsibilities

• Lead development and execution of prospective risk adjustment strategies to improve diagnosis capture and risk-adjusted revenue.
• Oversee provider-facing risk adjustment programs and engagement strategies to improve clinical documentation and coding accuracy.
• Assess regulatory changes and develop implementation plans ensuring compliant, optimized outcomes.
• Act as SME in bid filings, regulatory filings and financial planning across business units.

Skills

Leadership

Healthcare domain knowledge

Strategic planning

Data analysis

Project management

Communication

Regulatory knowledge

Education

Bachelor's Degree

Tools

Coding certificate

Job description

CareFirst BlueCross BlueShield in the greater Baltimore/Washington area seeks a Risk Adjustment Manager to lead prospective risk adjustment strategy across Medicare Advantage, Medicaid and ACA markets. The hybrid role requires collaboration with cross-functional teams and engagement with providers.

You will drive diagnosis capture accuracy, monitor KPIs and guide regulatory and financial forecasting while partnering with senior leadership to advance program objectives and ensure compliant,