Risk Adjustment Provider Performance Consultant

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); On-site; USD 119,000 - 145,000; Full time

Benefits offered by this job

Medical/dental/vision insurance

401(k)

Paid time off

Well-being benefits

Job summary

Blue Cross and Blue Shield of Massachusetts Inc. is seeking a Risk Adjustment Provider Performance Consultant in Hingham to lead the provider engagement strategy for risk adjustment.

You will work with clinic managers, billing leads, and coding supervisors to improve documentation and coding accuracy within CMS HCC guidelines. The role emphasizes cross-functional collaboration, data-driven interventions, and delivering executive-level reporting on ROI and network performance.

Qualifications

• 7+ years of Medicare Advantage risk adjustment, provider network management, provider education, or CDI within a health plan or large provider group.
• 5+ years of progressive experience in strategic program management, matrix leadership, or advanced provider engagement.
• Excellent communication and presentation skills to influence executive stakeholders.
• Deep understanding of value-based care models, provider contracting, and how risk adjustment intersects with HEDIS/Quality metrics.

Responsibilities

• Direct and independently manage the overarching provider engagement strategy for risk adjustment.
• Define strategic objectives, core workflows, and KPIs for network-wide provider outreach and engagement.
• Coordinate with Provider Contracting, Health and Medical Management, and Quality teams to integrate risk adjustment goals into contracts and incentive programs.
• Interpret complex provider performance data with Analytics to identify high-value intervention opportunities and documentation gaps.
• Provide advanced coding support and feedback on cases to clinical partners ensuring CMS HCC and ICD-10-CM alignment.
• Develop executive dashboards tracking engagement metrics, ROI of interventions, and overall network performance against targets.

Skills

Executive presence

Analytics acumen

Strategic integration

Technical knowledge

Education

Bachelor's degree in Healthcare Administration, Business, Nursing, Health Information Management, or related field

Tools

ICD-10-CM

CMS HCC methodologies

Job description

## Risk Adjustment Provider Performance ConsultantApply: Hingham: Full time: Posted 3 Days Ago: R08879## **Ready to help us transform healthcare? Bring your true colors to blue.****The Role**The Risk Adjustment Provider Performance Consultant role is a strategic, high-impact individual contributor role responsible for designing and executing comprehensive provider engagement and improvement strategies. Reporting to the Senior Director of Risk Adjustment and Analytics, this role serves as a principal subject matter expert and consultative partner to provider networks, ensuring complete and accurate medical record documentation.Acting as the critical bridge between clinical documentation, data analytics, and network strategy, this role will cultivate collaborative partnerships with provider clinic managers, billing leads, and coding supervisors to drive hands-on, localized performance improvement initiatives. Without direct people management responsibilities, this leader will rely on cross-functional influence, advanced data insights, and deep regulatory expertise to integrate risk adjustment efforts into the organization's broader value-based care and quality objectives.**Responsibilities*** Program & Strategy Leadership: Direct and independently manage the overarching provider engagement strategy for risk adjustment. Define strategic objectives, core workflows, and key performance indicators (KPIs) for network-wide provider outreach and engagement.* Strategic Provider Partnerships: Serve as the principal escalation point and strategic consultant for key provider group leadership regarding risk adjustment performance, documentation practices, and coding compliance.* Data-Driven Strategy & Analytics: Partner closely with the Data & Analytics team to interpret complex provider performance data. Utilize advanced analytics to independently identify high-value intervention opportunities, pinpoint documentation gaps, and segment provider networks for targeted outreach.* Coding Support & Opportunity Optimization: Proactively identify and action specific coding and documentation opportunities across the provider network. Provide advanced, consultative coding support and tailored feedback on complex cases to clinical partners, ensuring accurate capture of patient acuity and strict adherence to the latest CMS HCC and HHS coding guidelines.* Matrix Leadership & Cross-Functional Integration: Forge strategic alignment with Provider Contracting, Health and Medical Management, and Quality teams. Influence and guide cross-functional stakeholders to seamlessly integrate risk adjustment goals into broader value-based care contracts and incentive programs.* Executive Reporting: Design and present executive-level dashboards tracking provider engagement metrics, the ROI of strategic interventions, coding accuracy improvements, and overall network performance against enterprise targets.* Regulatory Strategy & Compliance: Act as a principal subject matter expert on CMS and HHS legislative and regulatory changes. Translate federal policy shifts into strategic operational plans and proactive communications for both internal leadership and provider partners.* Initiative Execution: End-to-end ownership of multi-year provider-facing risk adjustment initiatives, ensuring flawless execution, continuous monitoring, and alignment with enterprise financial and compliance objectives.**Qualifications**Education* Bachelor's Degree in Healthcare Administration, Business, Nursing, Health Information Management, or related field.* 7+ years of relevant experience in lieu of a Bachelor's Degree**Experience & Skills*** 7+ years of extensive experience in Medicare Advantage risk adjustment, provider network management, provider education, or clinical documentation improvement (CDI) within a health plan or large provider group.* 5+ years of progressive experience in strategic program management, matrix leadership, or advanced provider engagement, with a proven track record of driving large-scale initiatives without direct authority.* Executive Presence: Exceptional communication and presentation skills, with the ability to influence, consult, and persuade clinical leaders, executive stakeholders, and cross-functional partners.* Analytics Acumen: Strong ability to independently interpret complex performance data, collaborate with analytics teams, and translate findings into targeted, strategic provider interventions.* Strategic Integration: Deep understanding of value-based care models, provider contracting, and how risk adjustment intersects with HEDIS/Quality metrics.* Technical Knowledge: Mastery of ICD-10-CM guidelines, CMS HCC methodologies, and official medical record documentation standards.**Certifications*** AAPC Certified Risk Coder (CRC) – Required* Certified Professional Coder (CPC) *or* Certified Coding Specialist (CCS / CCS-P) – Required* Certified Documentation Improvement Practitioner (CDIP) *or* Certified Clinical Documentation Specialist (CCDS) – Strongly Preferred* Active Clinical License (e.g., RN, BSN) – Desired## Minimum Education Requirements:High school degree or equivalent required unless otherwise noted above## LocationHingham## Time TypeFull timeSalary Range: $118,710.00 - $145,090.00 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.This job is also eligible for variable pay.We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.