Risk Adjustment Manager

Position Summary 
The Risk Adjustment Manager is responsible for designing, executing, and continuously improving the organization’s Medicare and Medicare Advantage risk adjustment strategy. This role ensures accurate, compliant capture of patient acuity while driving provider engagement, operational excellence, and financial performance across employed and affiliate clinics. This is a strategy + execution role, bridging clinical operations, analytics, providers, coding teams, and health plan partners. 
Position may be remote with some travel required.

Key Responsibilities

 
Risk Adjustment Strategy & Performance 
Own the end-to-end implementation of Medicare and Medicare Advantage risk adjustment strategy, including prospective, concurrent, and retrospective models 
Establish annual RAF targets, forecasts, and performance monitoring cadence 
Translate CMS HCC guidance into actionable clinical and coding workflows 
Monitor coding intensity, suspect capture rates, and year-over-year RAF trends 
Provider Enablement & Engagement 
Partner with providers to improve documentation accuracy and chronic condition capture 
Lead provider education on risk adjustment, HCCs, and compliant documentation practices 
Collaborate with Provider Relations and Clinical Leadership to embed workflows into daily practice 
Support employed and affiliate clinics with tailored engagement strategies 
Operational Oversight 
Oversee coding workflows across internal and offshore teams 
Ensure quality assurance processes are in place for coding accuracy and compliance 
Coordinate chart review programs, vendor partnerships, and audit readiness 
Maintain CMS compliance and audit-defensible documentation standards 
Data, Analytics & Reporting 
Partner with analytics teams to develop RAF dashboards and performance reporting 
Interpret claims, encounter, and EMR data to identify gaps and opportunities 
Provide regular performance updates to executive leadership 
Support payer reporting and reconciliation efforts 
Cross-Functional Leadership 
Serve as the risk adjustment subject matter expert across the organization 
Collaborate with Quality, Care Management, Finance, and IT teams 
Support contract strategy and value-based care financial modeling 
Drive continuous improvement initiatives and best-practice standardization 
Experience 
Required 
Bachelor’s degree (clinical background preferred) 
5+ years of experience in Medicare and Medicare Advantage risk adjustment 
Strong working knowledge of CMS HCC models and documentation guidelines 
Experience supporting provider education and clinical workflow optimization 
Proven ability to manage distributed or offshore coding teams 
Strong analytical, communication, and stakeholder management skills 
US-based with availability to support provider and leadership engagement 
Preferred 
CRC, CPC, CCS, RN, or equivalent credential 
Experience in value-based care, ACOs, or delegated risk arrangements 
Experience with Revenue Cycle Management 
Experience supporting both employed and affiliate provider networks 
Familiarity with RAF forecasting and financial impact modeling