Manager, Risk Adjustment Programs in Boston, MA

$80K - $100K(Ladders Estimates)

Blue Cross Blue Shield of Massachusetts   •  

Boston, MA 02108

Industry: Finance & Insurance


5 - 7 years

Posted 55 days ago

The Manager, Risk Adjustment provides leadership to the centralized Risk Adjustment team. The Manager oversees the full suite of existing Medicare Advantage and Commercial Risk Adjustment activities. Meets financial and risk mitigation goals. Partners with Provider Network Management team on education. Participates in relevant Blue Cross Blue Shield Association and industry work groups.

The Manager, Risk Adjustment is responsible for:

  • vendor oversight for all revenue programs
  • Medicare Advantage retrospective HCC program
  • Medicare Advantage prospective program
  • Medicare Advantage Risk Adjustment Data Validation (RADV)
  • commercial risk adjustment retrospective assessment
  • commercial risk adjustment annual Risk Adjustment Data Validation (RADV)

Key Accountabilities:

  • Lead a multi-disciplinary team focused on the Medicare Advantage and Commercial Risk Adjustment programs
  • Manage annual Risk Adjustment Data Validation (RADV) audits; collaborate with Risk Adjustment Analytics team to perform a detailed analysis and document results.
  • Oversee multiple vendor relationships, monitor service level agreements, and participate in RFP planning
  • Ensure all processes and procedures are in place to meet divisional and corporate goal
  • Partner with other departments in the company (Finance, Audit and Controls, Legal, Actuarial, Provider Network Management) and the Association on risk adjustment models
  • Facilitate meetings and communicate results at all levels within the organization
  • Collaborate with Clinical Quality department on gap closure initiatives
  • Seek opportunities to positively impact and support Medicare Star goals, CAHPS, and HEDIS
  • Provide thoughtful and well-planned support and direction enabling staff members to successfully meet individual and program goals


  • In depth industry knowledge of State and Federal Risk Adjustment regulations for both the Medicare Advantage and Commercial Risk Adjustment required
  • Understanding of the CMS and State regulations and reimbursement methodologies related to Risk Adjustment
  • Critical thinking and creative problem-solving skills
  • Experience with complex data analysis
  • Draw upon diverse sources for ideas and inspiration in creative problem-solving activities
  • Ability to build cross-functional relationships both internally and externally. Foster teamwork and collaboration

Education/Relevant Experience:

  • Bachelor's degree or equivalent relevant work experience
  • Minimum five years' experience of relevant experience in health care organization
  • Three years in a Leadership / Project Management rolel
  • Background in Risk Adjustment a plus

Valid Through: 2019-10-14