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Medicare Risk Adjustment Program Manager (Non-Remote) Job in Lakeland, Florida

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Job Title: Medicare Risk Adjustment Program Manager (Non-Remote)

Employer:Reliance Medical Centers
Skills:Risk Adjustment in Health Plan or Medical Group Setting
Specialties:Managed Care
Required Certifications:CPC or CRC
Preferred Certifications:CPC or CRC
Required Experience:5 to 7 years
Preferred Experience:5 to 7 years
Location:4700 Exploration Ave. Lakeland 33812, FL, US
Date Posted:3/4/2021

The Medicare Risk Adjustment Program Manager will lead the overall risk adjustment program at Reliance Medical Centers. In this role, you will be a key strategic leader developing and executing a multi-product risk adjustment strategy aimed at ensuring accurate diagnosis risk coding for Reliance’s Medicare populations and achieving related revenue targets. The Medicare Risk Adjustment Program Manager will be responsible for building out core health plan-based risk adjustment operations, as well as developing innovative provider-based programs, and other product-specific risk adjustment strategies. Success will require competence in risk adjustment strategy, an ability to build and scale risk adjustment programs, and an ability to partner effectively with provider groups to design and implement point of care risk adjustment interventions.


  • Engaging stakeholders to define a system strategy for risk adjustment, including strategies for provider engagement, IT system capabilities. Strategy, planning, and end-to-end oversight to ensure accurate and complete risk adjustment.
  • Develop and implement Standard Operational Procedures, workflows, and process documentation policies for risk adjustment programs.
  • Monitor risk adjustment submissions as compared to expected revenue and proactively address gaps in data submissions and impacts to forecasting and budgets.
  • Accountable for ensuring ongoing key performance indicators measure productivity, quality, and overall impact of the company's risk adjustment program, including reporting KPI results on a monthly basis. Maintains risk adjustment performance management and reporting dashboard.
  • Direct the development of key analytics and data to support Risk Adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization.
  • Partner with Clinical and Financial Analytics teams to define opportunities and areas of focus to optimize risk adjustment performance across all products.
  • Develop member and provider engagement strategies, including the use of value-based payments, incentives, and other levers to encourage proactive risk management.
  • Expert on risk adjustment models; maintains current view of risk adjustment regulatory changes and product-specific risk model changes; ensures appropriate operational responses to regulatory and risk adjustment program changes.
  • Maximize return on investment in Risk Adjustment operations by reducing reliance on vendors and increasing validity of data submissions.
  • Maintain and oversee an effective Risk Adjustment submission process.
  • Serve as point person for relationships with health plan partners, including contracting and revenue management elements of risk arrangements as well as partner oversight of ongoing performance.
  • Provider site engagement and partnerships: Partner with provider account teams to communicate risk adjustment strategies and initiatives to provider groups; partner with provider groups to implement risk adjustment initiatives.
  • Internal stakeholder management: Ensures open communication and collaboration across all relevant internal departments/positions that intersect with risk adjustment team (Quality, Provider Relations, Product teams, etc.)
  • Specific tasks may include design and implementation of the following: Retrospective coding program; Provider education campaigns; Provider incentive programs; Audit and compliance programs; EMR optimization / other IT strategies.
  • Bachelor’s degree in Business or Healthcare Administration or related field required; Advanced degree preferred.
  • Required 5 years of experience in managed care and risk adjustment in a health plan or medical group setting.
  • Proven ability to align cross-functional teams and drive action to meet internal and external business and program goals and objectives.
  • Comprehensive knowledge of health plan activities with emphasis on Medicare or Medicaid Risk Adjustment programs.
  • Knowledge of regulatory risk adjustment requirements and processes and audit requirements.
  • Effective collaborative and proven process improvement skills.
  • Strong oral and written communication skills; ability to interact within all levels of the organization.
  • Demonstrated ability to successfully plan, organize and manage projects, critical thinking, problem-solving, and the analysis, interpretation, and evaluation of complex information.
  • Ability to conceptualize, create partnerships and facilitate change.
  • Thorough knowledge of quality measures HCC and RAF models.
  • Must be mission driven, clinically oriented, strong integrity and the ability to serve as a role model and mentor to staff and other leaders.
  • Must possess critical thinking and problem-solving skills, strategic planning ability, project management skills and the ability to make effective decisions.
  • Strong ability to forecast healthcare trends and lead change within the organization.
  • Effective leadership skills with development of patient focused environments.
  • Advanced statistical analysis skills
  • Proficient in MS Office applications such as Word, Excel, Access, PowerPoint, and Outlook
  • A license in one of the following is required:
    • Certified Procedural Coder (CPC)
    • Certified Risk Adjustment Coder (CRC)


Please contact Sandra Collins (Director, Revenue Cycle & Risk) at scollins@reliancemedicalcenters.com or apply online at https://recruiting.myapps.paychex.com/appone/MainInfoReq.asp?R_ID=3440658

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