The Risk Adjustment Compliance Project Manager is responsible for leading compliance focused initiatives that ensure the accuracy, integrity, and regulatory adherence of Medica's Risk Adjustment programs across Medicare Advantage, Medicaid, and ACA lines of business. This role provides subject matter expertise in regulatory requirements, audit readiness, and governance, and serves as a cross functional project leader for compliance, audit, and documentation initiatives. The Risk Adjustment Compliance Project Manager plays a critical role in maintaining audit readiness, mitigating compliance risk, and ensuring risk adjustment policies, procedures, and provider education aligning with CMS and state regulations.
Key AccountabilitiesAudit Oversight & Readiness (30%)- Coordinate and support internal and external audits, including RADV and other regulatory or operational reviews
- Serve as the primary point of coordination for audit requests, documentation retrieval, validation, and submission
- Track audit findings and collaborate with stakeholders on corrective action plans and remediation efforts
- Support ongoing audit readiness by strengthening controls, workflows, and documentation standards
Policy & Procedure Management (25%)- Develop, maintain, and update Risk Adjustment policies, procedures, and standard operating documentation
- Ensure documentation reflects current regulatory guidance, operational practice, and internal control requirements
- Partner with Compliance and Operational leaders to ensure consistent application and understanding of policies
- Maintain audit-ready documentation, including version control and governance standards
Risk Adjustment Compliance & Governance (20%)- Lead Risk Adjustment compliance initiatives to ensure adherence to CMS and state regulatory requirements
- Interpret and operationalize regulatory guidance impacting risk adjustment documentation, submission, and oversight
- Partner closely with Compliance, Quality, Legal, and Risk Adjustment Operations to align compliance activities with enterprise standards
- Identify compliance risks, gaps, and trends, and drive mitigation strategies to reduce regulatory exposure
Provider Education & Documentation Integrity (15%)- Collaborate with Provider Engagement and Quality teams to support provider education related to compliant documentation and risk adjustment standards
- Ensure provider education materials align with regulatory requirements and Medica compliance expectations
- Act as a subject matter expert for documentation and compliance-related questions impacting providers and internal teams
Project Management & Continuous Improvement (10%)- Lead compliance-driven risk adjustment projects from planning through execution
- Coordinate cross-functional efforts to implement regulatory changes or compliance improvements
- Identify and implement process improvements that strengthen program integrity and operational effectiveness
- Provide compliance status updates and reporting to leadership as needed
Required Qualifications - Bachelor's degree in Healthcare Administration, Business, Health Information Management, Compliance, or related field
- 5+ years of experience in healthcare operations, risk adjustment, healthcare compliance and/or audit, or regulatory support
Preferred Qualifications - Experience supporting RADV or CMS or DHS compliance audits
- Background in provider education, clinical documentation, or coding compliance
- Experience developing and maintaining healthcare policies and procedures
- Experience supporting Medicare Advantage, Medicaid, or ACA risk adjustment programs
Desired Skills- Demonstrated experience supporting regulatory and operational audits, with a strong understanding of Risk Adjustment programs and applicable CMS and state regulatory requirements
- Proven ability to lead compliance-focused initiatives through effective project management, organization, and analytical skills
- Excellent written and verbal communication skills, with the ability to collaborate across cross-functional teams and communicate complex regulatory requirements clearly to both technical and non-technical stakeholders
This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, St. Louis, MO, or Omaha, NE.
The full salary grade for this position is $70,200 - $120,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $70,200 - $105,315. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.
The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.
Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.
