Clinical Risk Adjustment Manager
Cotiviti
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $120,000 - $150,000 per year
About the role
- Monitor and interpret CMS, state Medicaid, and industry risk adjustment and quality regulations.
- Provide SME guidance to Product, Sales, and Account Management on RA policy and program implications.
- Partner with product teams to ensure solutions align with regulatory and audit requirements.
- Engage with industry groups (e.g., RISE, AHIP) to stay ahead of emerging trends.
- Translate regulatory changes into actionable product and roadmap recommendations.
- Serve as the primary internal authority on CMS-HCC risk adjustment models, coding guidelines, and regulatory requirements.
- Monitor and interpret changes to Medicare Advantage risk adjustment methodology, RADV audit requirements, and encounter data submission rules.
- Provide guidance on ICD-10-CM documentation requirements and HCC coding accuracy to ensure product compliance.
- Maintain active involvement in industry organizations such as RISE (Risk Adjustment).
- Build and leverage relationships within the risk adjustment and quality community to gather market intelligence.
- Represent Cotiviti at industry conferences, webinars, and working groups as a thought leader.
- Synthesize market trends, competitive insights, and customer feedback into actionable product recommendations.
- Partner with Product Management to inform roadmap decisions based on regulatory changes and market needs.
- Support Sales and Solution Consulting teams with clinical expertise during customer engagements and RFP responses.
- Collaborate with Compliance and Legal teams on regulatory interpretation and risk mitigation strategies.
- Complete all responsibilities as outlined in the annual performance review and/or goal setting.
- Complete all special projects and other duties as assigned.
Requirements
- Bachelor's degree in Healthcare Administration, Nursing, Health Information Management, or related clinical field.
- 5+ years of experience in Medicare Advantage risk adjustment, quality/HEDIS operations, or healthcare analytics.
- Deep knowledge of CMS-HCC risk adjustment models, RADV audits, and encounter data submission requirements.
- Strong understanding of Star Ratings methodology, and quality improvement programs.
- Experience interpreting CMS regulations, Federal Register notices, and healthcare policy changes.
- Demonstrated ability to translate complex regulatory requirements into business and product implications.
- Excellent communication skills with ability to present to both technical and executive audiences.
Benefits
- medical, dental, vision, disability, and life insurance coverage
- 401(k) savings plans
- paid family leave
- 9 paid holidays per year
- 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Medicare Advantage risk adjustmentCMS-HCC risk adjustment modelsRADV auditsICD-10-CM documentationHCC coding accuracyStar Ratings methodologyquality improvement programshealthcare analyticsregulatory interpretationrisk mitigation strategies
Soft Skills
communication skillsrelationship buildingmarket intelligence synthesiscollaborationguidance provisionthought leadershippresentation skillsproblem-solvingstrategic thinkingcustomer engagement
Certifications
Bachelor's degree in Healthcare AdministrationBachelor's degree in NursingBachelor's degree in Health Information Management