Clinical Risk Adjustment Manager

Job Summary

A company is looking for a Clinical Risk Adjustment Manager.

Key Responsibilities

• Monitor and interpret CMS, state Medicaid, and industry risk adjustment and quality regulations
• Provide subject matter expert guidance to Product, Sales, and Account Management on risk adjustment policy and program implications
• Engage with industry groups to stay ahead of emerging trends and translate regulatory changes into actionable product recommendations

Required Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Health Information Management, or related clinical field
• 5+ years of experience in Medicare Advantage risk adjustment, quality/HEDIS operations, or healthcare analytics
• Deep knowledge of CMS-HCC risk adjustment models, RADV audits, and encounter data submission requirements
• Strong understanding of Star Ratings methodology and quality improvement programs
• Experience interpreting CMS regulations and healthcare policy changes