Risk Adjustment Lead – Medicare & ACA Coding

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

Benefits offered by this job

Medical/dental/vision insurance

401(k) matching

Paid time off

Job summary

Blue Cross Blue Shield of Massachusetts seeks a Manager of Medicare & Commercial Risk Adjustment to lead a team of certified risk adjustment coders and QA auditors. You will drive accurate coding and medical record reviews to support CMS/MA and HHS/ACA submissions, while overseeing internal, vendor, and offshore partners across MA and ACA lines.

The role requires expertise in CMS-HCC, CMS-RADV, and HHS-RADV, strong leadership, and the ability to educate providers and stakeholders on

Qualifications

• Minimum five (5) years of Risk Adjustment Coding experience including hands-on experience with Medicare Advantage (CMS-HCC) and ACA marketplace (HHS-HCC) risk adjustment models and CMS-RADV and HHS-RADV audit support.
• Minimum three (3) years in a managerial or supervisory capacity overseeing coding teams and quality assurance processes.
• Active AAPC Certified Risk Adjustment Coder (CRC) credential required.
• Active CPC or CCS credentials – accepted in lieu of CRC.
• Extensive knowledge of ICD-10-CM coding guidelines and CMS-HCC, HHS-HCC risk adjustment methodologies.

Responsibilities

• Lead and develop a team of certified professional coders and QA auditors.
• Oversee vendor and offshore coding partners to ensure quality and compliance.
• Ensure accurate and compliant diagnosis coding to support MA and ACA risk adjustment models.
• Validate medical record reviews and QA reviews for alignment with coding submissions.
• Implement and manage QA coding review programs to monitor accuracy and compliance.
• Support audit readiness activities spanning CMS-RADV, HHS-RADV, and other regulatory audits.
• Collaborate with compliance and audit teams to resolve findings and implement corrective actions.
• Integrate NLP/AI-assisted coding tools with quality validation before submission.
• Develop and deliver ongoing education programs for providers and internal stakeholders.

Skills

Risk Adjustment Coding

CMS-HCC knowledge

CMS-RADV knowledge

Leadership / Team Management

Provider Education

Education

Bachelor's degree in Business Administration/Management, Health Information Management, Healthcare Administration (or equivalent)

Tools

NLP/AI-assisted coding tools

Job description

Blue Cross Blue Shield of Massachusetts seeks a Manager of Medicare & Commercial Risk Adjustment to lead a team of certified risk adjustment coders and QA auditors. You will drive accurate coding and medical record reviews to support CMS/MA and HHS/ACA submissions, while overseeing internal, vendor, and offshore partners across MA and ACA lines.

The role requires expertise in CMS-HCC, CMS-RADV, and HHS-RADV, strong leadership, and the ability to educate providers and stakeholders on