Prospective Risk Adjustment Leader (Hybrid)

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

Benefits offered by this job

Hybrid work model

Comprehensive benefits package

401k contribution programs

Job summary

CareFirst is seeking a Risk Adjustment Manager to lead the development and execution of prospective risk adjustment strategies across Medicare Advantage, Medicaid, and ACA markets. The role focuses on improving diagnosis capture, risk scores, and revenue while coordinating with providers and internal teams in a hybrid work setting in the greater Baltimore/Washington area.

The candidate will oversee program performance, engage providers, and ensure compliance with evolving regulations,

Qualifications

• Bachelor's degree or equivalent experience.
• 5 years experience in a healthcare payer environment.
• 1 year supervisory or leadership experience within Government Programs and Risk Adjustment

Responsibilities

• Lead development and execution of prospective risk adjustment strategies to improve diagnosis capture, risk scores, and revenue.
• Develop and oversee provider-facing risk adjustment programs and engagement strategies.
• Assess impact of risk adjustment regulations and forecast financial performance.
• Act as SME to guide stakeholders in bid filings, regulatory filings, and reporting.

Skills

Leadership

Healthcare payer

Regulatory knowledge

Data analytics

Provider engagement

Communication

Education

Bachelor's Degree

Job description

CareFirst is seeking a Risk Adjustment Manager to lead the development and execution of prospective risk adjustment strategies across Medicare Advantage, Medicaid, and ACA markets. The role focuses on improving diagnosis capture, risk scores, and revenue while coordinating with providers and internal teams in a hybrid work setting in the greater Baltimore/Washington area.

The candidate will oversee program performance, engage providers, and ensure compliance with evolving regulations,