Risk Adjustment Program Lead: Strategy & Ops

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

Job summary

CommunityCare HMO Inc. is seeking a Risk Adjustment Operations Leader to oversee day-to-day activities across vendor management, chart retrieval, coding quality, analytics, reporting, and audits.

You will drive process improvements, monitor performance, and ensure CMS and internal compliance for prospective and retrospective risk adjustment initiatives. The role emphasizes collaboration with analytics teams, development of dashboards, and leadership communications to optimize RAF results and

Qualifications

• Bachelor’s degree in analytics, statistics, health informatics, business, or related field with a minimum of three (3) years of healthcare analytics, risk adjustment, or population health experience.
• CRC, CPC, or other relevant licenses required.
• Prior experience supporting production planning.
• Prior experience with RAF projections preferred.
• Prior experience with prospective programs and provider engagement models preferred.

Responsibilities

• Oversee day-to-day risk adjustment operations and ensure efficient execution across program workflows.
• Identify process gaps and implement improvements across retrieval, coding, reporting, vendor operations, and data workflows.
• Establish, monitor, and manage key performance indicators to track operational performance, RAF performance, coding accuracy, retrieval rates, and vendor outcomes.
• Manage risk adjustment vendors for coding, retrieval, analytics, and prospective programs, ensuring SLA adherence and coding accuracy standards.
• Oversee vendor audits, corrective action plans, and monthly invoice reconciliation against performance and contractual requirements.
• Lead medical record retrieval strategies to improve chart capture rates, reduce turnaround times, and address low-performing provider sites.
• Oversee coding quality assurance processes, including vendor over-reads, internal audits, and compliance with CMS guidelines and organizational policies.
• Coordinate RADV audit readiness activities, including record retrieval, submission tracking, audit response, documentation, and regulatory review preparation.
• Analyze audit results, data issues, and process gaps to identify root causes and implement operational improvements.
• Oversee retrospective chart reviews and prospective engagement programs to support suspect capture, gap closure, new member engagement, and program effectiveness.
• Partner with analytics teams to develop dashboards, reporting, vendor scorecards, ROI analysis, WNRAR reporting, and actionable leadership insights.
• Collaborate cross functionally to resolve issues, improve reporting accuracy, support submissions, and streamline risk adjustment operations.
• Perform other job related duties as required or assigned.

Skills

Vendor management

RADV analytics

CMS guidelines

Cross-functional leadership

Data-driven decisions

Dashboards & reporting

Communication to leadership

Healthcare analytics

Education

Bachelor's degree in analytics, statistics, health informatics, business, or related field

CRC, CPC or other relevant licenses

Job description

CommunityCare HMO Inc. is seeking a Risk Adjustment Operations Leader to oversee day-to-day activities across vendor management, chart retrieval, coding quality, analytics, reporting, and audits.

You will drive process improvements, monitor performance, and ensure CMS and internal compliance for prospective and retrospective risk adjustment initiatives. The role emphasizes collaboration with analytics teams, development of dashboards, and leadership communications to optimize RAF results and