Manager, Medicare & Commercial Risk Adjustment

Job description

Ready to help us transform healthcare? Bring your true colors to blue. The Role The Manager of Medicare & Commercial Risk Adjustment leads a team of certified risk adjustment coders and QA auditors responsible for accurate risk adjustment coding and medical record review supporting submissions to Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage (MA) health plans and Department of Health and Human Services (HHS) Affordable Care Act Marketplace (ACA) Qualified health plans. This role leads all RA coding and QA operations across MA and ACA lines of business, encompassing internal coders, vendor and offshore coding partners, NLP/AI-assisted coding technologies, and coding outputs, while ensuring compliance with CMS and HHS methodologies across all coding platforms. RA coding output files are reviewed and finalized by this team prior to handoff to the RA Data Analytics teams responsible for EDPS (MA) and EDGE server (ACA) data submissions. This role also builds provider relationships through education and training, collaborates with business partners to meet divisional goals, and drives process improvements. The Manager acts as a subject matter expert on MA (CMS-HCC, CMS-RADV) guidelines as well as ACA (HHS-HCC, HHS-RADV) requirements, working closely with the RADV Compliance Senior Manager to support audit readiness across internal and external (CMS-RADV, HSS-RADV) audit cycles. Responsibilities Lead and develop a team of certified professional coders and quality assurance auditors. Oversee vendor and offshore coding partners to ensure consistent quality and compliance. Ensure accurate and compliant diagnosis coding to support MA and ACA risk adjustment models across RA coding operations. Validate medical record reviews and QA reviews to confirm diagnostic documentation aligns with coding submissions. Implement and manage quality assurance coding review programs to monitor coding accuracy and compliance. Support and facilitate audit readiness activities spanning internal auditing and monitoring and CMS-RADV, HHS-RADV, and other regulatory audit requirements. Collaborate with compliance and audit teams to resolve findings and ensure corrective actions are implemented. Identify opportunities for improving coding workflows and documentation quality. Integrate technology solutions, including NLP and AI-assisted coding tools, ensuring quality validation before submission. Develop and deliver ongoing education programs for providers and internal stakeholders on risk adjustment documentation and coding best practices. Build trusted relationships with providers to encourage compliant, accurate documentation. Maintain current knowledge of industry CMS-RADV and HHS-RADV risk adjustment policies, coding regulations, and audit protocols. Serve as the subject matter expert on risk adjustment coding and documentation standards across MA and ACA models. Partner with business units, compliance, analytics, and IT to align coding strategies with overall organizational goals. Qualifications Education Bachelor's Degree in Business Administration/Management, Health Information Management, Healthcare Administration, or equivalent; OR minimum of five (5) years of relevant experience in lieu of a degree. Experience & Skills Minimum five (5) years of Risk Adjustment Coding experience including hands-on experience with Medicare Advantage (CMS-HCC) and ACA marketplace (HHS-HCC) risk adjustment models and CMS-RADV and HSS-RADV audit support. Minimum three (3) years in a managerial or supervisory capacity overseeing coding teams and quality assurance processes. Active AAPC Certified Risk Adjustment Coder (CRC) credential required. Active Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credential – accepted in lieu of CRC. Extensive knowledge of ICD-10-CM coding guidelines and CMS-HCC, HHS-HCC risk adjustment methodologies, including HHS-RADV and ACA-specific documentation and coding standards. Ability to interpret clinical documentation according to audit-defensible coding standards. Strong analytical, critical-thinking, and documentation skills. Excellent written and verbal communication skills. Preferred Qualifications Certified Professional Medical Auditor (CPMA) or Registered Health Information Administrator (RHIA) – Preferred Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location Hingham Time Type Full time Salary Range: $104,040.00 - $127,160.00 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. WHY Blue Cross Blue Shield of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue. At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our " How We Work " Page.