Risk Adjustment Operations Manager

CommunityCare HMO, Inc.; Tulsa (OK); On-site; USD 90,000 - 120,000; Full time

Job summary

CommunityCare HMO, Inc. in Tulsa, OK seeks a seasoned professional to oversee the risk adjustment program's day-to-day execution, performance, and optimization across vendor management, medical record retrieval, coding quality, analytics, reporting, and audit readiness.

The role focuses on process improvements, regulatory compliance with CMS, and support for retrospective and prospective risk adjustment initiatives, including dashboard development and leadership reporting.

Qualifications

• Understanding of CMS-HCC and RADV models.
• Experience managing vendors with performance accountability.
• Knowledge of CMS guidelines and RADV audits.
• Ability to lead cross-functional initiatives and process improvements.
• Experience with reporting tools, dashboards, and data-driven decisions.
• Excellent written and verbal communication with senior leadership.

Responsibilities

• Oversee risk adjustment operations and program workflows.
• Identify process gaps and implement improvements in retrieval, coding, reporting, and vendor operations.
• Set and monitor KPIs for RAF, coding accuracy, retrieval rates, and vendor outcomes.
• Manage risk adjustment vendors, audits, and invoice reconciliation.
• Lead medical record retrieval strategies to improve chart capture and turnaround times.
• Oversee coding quality assurance and CMS guideline compliance.
• Coordinate RADV audit readiness activities and regulatory review preparation.
• Analyze audit results and root causes to implement improvements.
• Collaborate with analytics to develop dashboards and leadership insights.
• Perform other job related duties as required.

Skills

Medicare Advantage risk adjustment

Vendor management

CMS guidelines

RADV audits

Cross-functional leadership

Data reporting & dashboards

Communication to leadership

Background check

Education

Bachelor's degree in analytics/health informatics/business

CRC or CPC license

3+ years healthcare analytics/risk adjustment experience

RAF projections experience

Job description

CommunityCare HMO, Inc. in Tulsa, OK seeks a seasoned professional to oversee the risk adjustment program's day-to-day execution, performance, and optimization across vendor management, medical record retrieval, coding quality, analytics, reporting, and audit readiness.

The role focuses on process improvements, regulatory compliance with CMS, and support for retrospective and prospective risk adjustment initiatives, including dashboard development and leadership reporting.