Clinical Risk Adjustment Manager

Key Responsibilities:

• Monitor and interpret CMS, state Medicaid, and industry risk adjustment and quality regulations.
• Provide SME guidance to Product, Sales, and Account Management on RA policy and program implications.
• Partner with product teams to ensure solutions align with regulatory and audit requirements.

Risk Adjustment Expertise:

• Serve as the primary internal authority on CMS-HCC risk adjustment models, coding guidelines, and regulatory requirements.
• Monitor and interpret changes to Medicare Advantage risk adjustment methodology, RADV audit requirements, and encounter data submission rules.
• Provide guidance on ICD-10-CM documentation requirements and HCC coding accuracy to ensure product compliance.

Cross-Functional Collaboration:

• Partner with Product Management to inform roadmap decisions based on regulatory changes and market needs.
• Support Sales and Solution Consulting teams with clinical expertise during customer engagements and RFP responses.
• Collaborate with Compliance and Legal teams on regulatory interpretation and risk mitigation strategies.