Risk Adjustment Manager - Prospective (Hybrid)

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

Benefits offered by this job

Health benefits

401k retirement plan

Hybrid work model

Job summary

CareFirst, Inc. in Reston, VA is seeking a Risk Adjustment Manager to lead prospective risk adjustment strategy across Medicare Advantage, Medicaid and ACA markets. The role focuses on performance, governance, and provider engagement while guiding cross-functional teams.

Hybrid work with some days at CareFirst locations; responsibilities include regulatory alignment, financial forecasting, and strategic planning in collaboration with internal and external stakeholders.

Qualifications

• Bachelor's degree required; 4+ years additional experience in lieu of degree accepted
• 5 years progressive responsibility in a healthcare payor environment
• 1 year supervisory or leadership experience in Government Programs and Risk Adjustment
• Masters degrees preferred: MBA, MHA or related population health field

Responsibilities

• Lead development and execution of prospective risk adjustment strategies across all lines of business
• Develop provider engagement strategies, incentive programs, and training campaigns
• Assess regulatory changes and develop compliant strategies for forecasting, filings and planning
• Act as a liaison between business units and risk adjustment group to ensure collaboration and reporting

Skills

Leadership

Project management

Healthcare payor domain

Data analytics

Regulatory knowledge

Communication

Education

Bachelor's Degree

MBA / MHA / MPH (preferred)

Job description

Resp & Qualifications

PURPOSE:

The Risk Adjustment Manager plays a critical role in the development and execution of the corporate risk adjustment strategy. The role serves as a dedicated resource within the organization for Medicare Advantage, Medicaid and ACA markets, coordinating and leading the end to end strategy by applying improvements and driving cost-effective risk adjustment actions across all organizational populations and products. This role will focus on CareFirst's Prospective Risk Adjustment strategy.

We are looking for an experienced people leader in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and at least two days a week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• Lead the development and execution of prospective risk adjustment strategies designed to improve diagnosis capture accuracy, member risk score performance, and risk-adjusted revenue outcomes across all lines of business. Establish and monitor key performance indicators (KPIs), objectives and key results (OKRs), return on investment (ROI), program milestones, and operational dashboards. Communicate program performance, risks, opportunities, and action plans to senior leadership, and drive accountability for achieving organizational goals. Supported by recent internal prospective program initiatives focused on provider engagement, incentive programs, and performance tracking.
• Develop and oversee provider-facing risk adjustment programs focused on improving clinical documentation, coding accuracy, condition recapture, and prospective diagnosis capture. Lead provider engagement strategies, incentive programs, point-of-care initiatives, educational campaigns, and vendor partnerships. Collaborate with network management, provider relations, clinical teams, and external partners to expand provider participation and improve program effectiveness. This aligns with ongoing provider incentive and provider portal strategies discussed in your prospective program materials.
• Assess the operational and financial impact of evolving risk adjustment regulations, methodologies, and industry practices. Develop implementation strategies to ensure compliance while optimizing business outcomes. Serve as a subject matter expert for financial forecasting, bid development, revenue performance analysis, regulatory filings, and strategic planning. Partners with internal and external stakeholders, including regulators, industry organizations, and cross-functional business leaders, to advance organizational objectives and identify opportunities for program enhancement.
• Act as a liaison between the business units and the risk adjustment group by promoting a positive environment of collaboration and excellent customer service. Serve as an SME to guide the key stakeholders in bid filings, regulatory filings, and financial performance planning and reporting.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 5 years experience of progressive responsibility in a healthcare payor environment, 1 year experience with supervisory or demonstrated progressive leadership experience within Government Programs and Risk Adjustment functional areas

Preferred Qualifications:

• Masters in business administration, Masters in Health Administration or Masters in Public or Population health.

Knowledge, Skills and Abilities (KSAs)

• Knowledge and experience across all regulatory guidelines on Risk Adjustment.
• Experience successfully planning and leading presentations to physicians, internal stakeholders, and C-suite with a focus on coding data and analytics.
• Experienced with effective physician/provider collaborative training to support workflow adjustments to improve clinical coding quality.
• Successful completion of a Coding Certificate program from an accredited organization (i.e., CPC, CRC,CPMA from AAPC, or CCS, CCS-P from AHIMA).
• Strong leadership skills, vendor oversight skills and an experience in payer, provider and industry collaboration.
• Ability to work in a fast-paced environment and drive consistent actions across a matrixed environment.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $105,040 - $194,981

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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