Manager, Risk Adjustment

Gold Kidney Health Plan

Full Time
Posted 4 months ago


Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient, every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No-Limits Mindset, and Results Oriented.

Purpose and Scope:

The Manager, Risk Adjustment, will help establish, develop, and maintain key operational initiatives to drive Risk Adjustment Program activities. The incumbent will be responsible for driving market-level commitments, execution of Value Based campaigns, and managing service levels and commitments levels with the company’s revenue commitments. The incumbent is for a valued thought leader, who will be responsible for facilitating and driving the definition and prioritization of complex risk adjustment improvement strategies.

Principal Duties and Responsibilities:

  • Establishes, develops, and implements Risk Adjustment activities across different Markets to ensure successful execution of Risk Adjustment programs while maintaining programs compliantly.
  • Creates & executes out of box thinking/creative way to execution of RA programs.
  • Ensures all activities are fully executed through end-to-end process from provider to Centers for Medicare and Medicaid Services (CMS), State and federal regulatory requirements.
  • Ensures early detection of major risks and interdependencies for program initiatives across the entire network.
  • Promotes transparency and equal coverage among stakeholders.
  • Combines an in-depth knowledge of Risk Adjustment business, products and services with a solid understanding of industry trends to develop differentiated solutions to maximize and grow partner relationships.
  • Works with stakeholders across the system to ensure effective coordination.
  • Provides updates to Risk Adjustment Stakeholders on program operational activities – creates dashboards and operational metrics to demonstrate program success.
  • Manages activity of cross-functional teams to help support reporting capabilities.
  • Oversee the risk adjustment coding and data validation programs.
  • Monitor daily queue volumes, prepare executive reports, oversee the coding of risk adjustment audits, develop & support risk adjustment infrastructure and maintain ROI by managing various inputs/outputs.
  • Evaluate and manage the risk adjustment strategy across all functional areas that impact assigned products.
  • Develop and maintain all policy and procedures for departmental processes.
  • Develop and implement action plans by partnering with all departments affecting assigned products and plans, to address issues identified by the business units, including detailed workplans, issue logs, and progress reports.
  • Assist in composing provider education for correct coding according to state and federal risk adjustment guidelines.
  • Work with vendor coding leadership to ensure risk adjustment work being undertaken on behalf of Gold Kidney meets all state and federal guidelines for risk adjustment code capture and contractual service level agreements.
  • Prepare dashboards, reports, and analytics for senior management and identify improvement opportunities.
  • Create, reviews and maintains operational workflows that are efficient and effective.
  • Work with medical leadership to enhance electronic health record systems and tools for physician network to use.
  • Successfully interacts with physicians and physician office staff to engage in programs developed.
  • Oversees claims/encounter data collection, processing, submission and data reconciliation efforts with provider network and health plans ensuring that collected data is processed all the way to CMS’s RAPS system as well as EDPS system.
  • Develops and implements approaches to measure the effectiveness of physician specific initiatives for improving risk score accuracy.
  • Maintains expert knowledge of the risk adjustment process, including regulatory changes impacting the program.
  • Ensures company approved compliance programs and P&Ps are upheld across the market.
  • Collaborates across the company and with vendors to help ensure the integration and alignment of risk adjustment strategies.
  • Leads staff assigned to risk adjustment; provides guidance and engagement of staff; and builds effective teams (both internally and with vendors) to achieve established goals and within established budgets.
  • Demonstrates the ability to lead and influence others positively to achieve desired goals.

Physical Demands and Working Conditions:

  • The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Occasional travel may be required.




Bachelor’s degree in applicable field or equivalent experience required. 5+ years of project management, operations, or quality improvement in the healthcare industry. Experience in risk adjustment or medical record audit preferred. Thorough knowledge of administrative, data management and audit functions. Management/supervisory experience required.

Experience and Required Skills:

5+ years of project management, operations, or quality improvement in the healthcare industry. Experience in risk adjustment or medical record audit preferred. Thorough knowledge of administrative, data management and audit functions. Management/supervisory experience required.

License and Certifications:

CPC, CPC-H, CPC-P, CCS, CCs-P, RHIA or CPMA preferred. CRC or MARSI risk adjustment certification preferred.


I will review and comply with the Code of Business Conduct and all relevant Company and Division policies and procedures, and local, state, and Federal laws and regulations. I acknowledge that I have read and accepted this job description.  I understand what is expected of me in this position, and I am able to perform the essential functions as outlined with or without reasonable accommodation.  Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position.  If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate supervisor or my Human Resources representative.

Job Features

Job CategoryClinical Services

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