Resp & Qualifications

PURPOSE:
The Risk Adjustment Supervisor supports the execution of the corporate risk adjustment strategy across Medicare Advantage, Medicaid, and ACA markets. This role ensures operational compliance by supervising day-to-day activities, monitoring performance metrics, and facilitating cross-functional collaboration to drive cost-effective risk adjustment actions and optimize health plan performance to achieve equitable resource allocation based on population health risk profiles. This role is also responsible for overseeing the accurate collection, submission, and validation of risk adjustment data, ensuring compliance with regulatory standards and optimizing organizational performance under various risk adjustment programs.

We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• Supervise day-to-day activities and operational processes of the risk adjustment team - including medical record retrieval and data submission to CMS and other regulatory agencies, ensuring timely execution of tasks and adherence to regulatory requirements. Provide coaching, mentorship and performance management to meet productivity targets and regulatory deadlines. Assign and monitor workloads, prioritize activities, and drive ongoing professional development on CMS, HHS, HCC requirements
• Identify and resolve process bottlenecks, ensuring timely completion of deliverables in line with plan requirements. Serve as point of contact to triage and resolve issues related to data discrepancies or operational interruptions to maintain compliance with regulatory requirements. Assists leadership in the review and development of quality controls to ensure abstraction, data submissions and documentation comply with state and regulatory agencies. Provide actionable feedback to staff for continuous improvement.
• Monitor and maintain key performance indicators (KPIs, OKRs and ROI metrics) and program dashboards; tracking action items and escalating risks or barriers to leadership to ensure that all risk adjustment activities fully comply with Medicare, Medicaid, ACA, and state-specific regulations. Remain current on changes to risk adjustment models and coding guidelines, updating protocols and educating the team as needed.
• Engage with both internal stakeholders and external partners to improve business outcomes by promoting effective collaboration and customer service excellence. Analyze health plan outcomes and workflows to identify opportunities for improvement.

SUPERVISORY RESPONSIBILITY:
This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 3 years progressive work experience in a risk adjustment, medical coding or health insurance operations within a health plan or managed care environment with demonstrated leadership.

Knowledge, Skills and Abilities (KSAs)

• Knowledge and experience across all regulatory guidelines on Risk Adjustment.
• Successful completion of a Coding Certificate program from an accredited organization (i.e., CPC, CRC, CPMA from AAPC, or CCS, CCS-P from AHIMA).
• Ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines and workloads that can be varied for extended periods of time.
• Must be able to handle multiple customer service demands from internal and external stakeholders, within set expectations for service excellence.
• Ability to communicate with tact to all levels of staff and to exercise sound judgment. Strong leadership and vendor oversight skills with experience in payer, provider and industry collaboration.

Salary Range: $80,136 - $165,281

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

ACA Risk Adjustment

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

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