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Risk Adjustment Market Performance Overview

This role delivers the enterprise risk adjustment plan within assigned markets, turning priorities into structured workplans and carrying initiatives through to completion while reporting progress, risks, and recommendations to the Director. It partners across clinical, operational, coding, analytics, and provider-facing teams to identify opportunities, improve risk capture, and achieve measurable outcomes through effective delivery, analytics, provider engagement, workflow improvement, and compliance.

The role requires strong knowledge of the end-to-end risk adjustment process, including documentation, coding, risk stratification, claims and encounter submission, reconciliation, CMS requirements, and audit readiness. Success requires strong analytical, communication, and relationship-building skills and the ability to influence change.

Essential Functions:

Risk Adjustment Delivery

• Lead delivery of risk adjustment initiatives and priorities for assigned clients or markets.
• Translate risk adjustment plans and recommendations into structured workplans with clear milestones, owners, timelines, and dependencies.
• Maintain project trackers and a consistent follow-up cadence, keeping initiatives moving from launch through completion and measurable results.
• Coordinate with clinical, operational, coding, analytics, and provider-facing teams.
• Identify barriers and opportunities and escalate issues appropriately.
• Provide regular status updates to the Director, flagging delays, risks, and decisions needed early.

End-to-End Risk Capture

• Support the full risk adjustment continuum, including attribution, access, suspecting, gap analysis, point-of-care support, documentation, coding, retrospective review, submission, reconciliation, and audit readiness.
• Apply knowledge of Medicare Advantage, ACA/commercial, MSSP/ACO, Medicaid, and other value-based care models.
• Identify opportunities to improve accurate condition capture and recapture.
• Support post-visit follow-up and resolution of barriers affecting credited risk capture.
• Trace diagnoses from documentation through coding, submission, acceptance, and payer credit; resolve breakdowns with responsible teams.

Analytics & Performance Management

• Partner with analytics teams to interpret reporting and identify performance opportunities.
• Evaluate risk adjustment activity, trends, gaps, and outcomes.
• Connect performance to clinical accuracy, RAF/MLR, financial impact, and operational results.
• Present market performance updates and recommendations to clinical, operational, and market leadership; contribute to executive updates led by the Director.

Provider & Client Partnerships

• Build effective relationships with physicians, client leadership, coding, analytics, and provider-facing teams.
• Work with providers and support teams to understand documentation and coding barriers.
• Translate coding and documentation findings into practical guidance and education priorities for providers and support teams.
• Influence process and behavior changes through collaboration and practical recommendations.

Workflow & Process Improvement

• Advise on workflow design, documentation practices, and process changes, applying an understanding of how coding and documentation accuracy affect risk adjustment, patient care, and credited outcomes.
• Identify opportunities to improve risk adjustment workflows, including suspecting, prioritization, documentation support, follow-up, and escalation.
• Partner with appropriate teams to implement workflow improvements.
• Develop reusable tools, trackers, educational materials, and processes.
• Identify opportunities to use AI-enabled tools and automation to improve efficiency and quality.

Compliance & Audit Readiness

• Support compliance with CMS guidance, coding requirements, and organizational standards across risk adjustment activities.
• Promote accurate, documentation-supported risk capture.
• Monitor for aberrant or unsupported patterns and escalate concerns appropriately.
• Support RADV and other audit readiness activities.
• Reinforce documentation and coding practices that keep risk capture accurate, defensible, and reflective of each patient's health status.

Continuous Improvement & Results

• Monitor performance against established market or client baselines.
• Evaluate intervention effectiveness, opportunity conversion, cost per chart, and provider burden.
• Support improvements in accurate condition capture, recapture, provider responsiveness, and operational efficiency.
• Share lessons learned and successful practices with relevant teams.

Education and Experience:

Education: 

• Bachelor's degree in healthcare, business, health information management, or related field; equivalent experience may be considered.

Experience: 

• 5+ years of risk adjustment experience, including project leadership and direct interaction with providers, clients, or market stakeholders.
• Experience in a provider, payer, or health plan environment; experience in both is preferred.
• Experience with CMS-HCC V28 and multiple lines of business, such as Medicare Advantage, ACA/commercial, MSSP/ACO, or Medicaid.
• Experience with prospective, concurrent, and retrospective risk adjustment.
• Experience partnering with analytics, coding, clinical, operational, and provider-facing teams.
• Experience leading multiple priorities and influencing change without direct authority.
• Demonstrated experience managing cross-functional projects from planning through completion; PMP or formal project management training preferred.
• Experience with additional risk models, BI tools, Epic, automation, or AI-enabled tools preferred.

Licensure/Certification: 

• Active coding certification required (CRC preferred; CPC, CCS, or equivalent accepted).

Knowledge Skills and Abilities:

• Strong knowledge of risk adjustment, CMS requirements, coding guidelines, and audit standards, including how coding and documentation accuracy affect risk adjustment performance and patient care.
• Strong analytical, critical-thinking, and problem-solving skills.
• Ability to translate complex data into clear business recommendations.
• Strong project management and organizational skills, with a proven ability to move multiple initiatives across teams to on-time completion.
• Strong provider engagement and relationship-building skills.
• Excellent written, verbal, presentation, and executive communication skills.
• Ability to influence and collaborate across a complex organization.
• Ability to balance enterprise standards with client-specific needs.
• Proficiency with Microsoft Office and spreadsheet-based analysis.
• Comfortable using AI-enabled tools to improve productivity and workflow efficiency.
• Ability to travel approximately 20% annually.

What You’ll Get: 

• Benefits the first of the month following your hire date: Medical, Dental, Vision, Life, Long/Short Term Disability, Health Savings Account/Flexible Spending Account, Fraud Protection, Legal, Pet and other fringe benefits
• Generous PTO policy + 9 paid holidays
• 401k match + profit sharing
• Tuition reimbursement
• Wellness program
• Opportunities for professional growth and mentorship
• Emphasis on work-life balance