Risk Adjustment Manager

Sanitas Medical Centers
June 26, 2019
Miami, FL
Job Type


The position is responsible for the development, refinement, maintenance, monitoring and oversight of the Diagnosis Accuracy strategies and initiatives to ensure the accuracy and integrity of diagnostic data submitted to the payer and the Centers for Medicare and Medicaid Services (CMS). The position develops, oversees and coordinates collection, validation and submission of pertinent data from both internal and external sources. Leads a cross-functional team in charge of identifying and implementing improvement opportunities for clinical/coding provider training, medical record documentation, data gathering, annual visit activities, and health plan / CMS reporting to ensure accuracy and compliance with mandated guidelines.

  • Understand HHS and HCC models to create strategies to improve the Department’s overall performance.
  • Supervise and enhance the Medical Coding processes to adjust the population’s risk.
  • Medical coding management: Manage a department of over 45 Medical Coding Specialists, through 3 direct reports.
  • Lead the overall strategy and/or coordinates cross-functional initiatives to improve diagnosis accuracy to reach company set goals, including but not limited to:
    • Identifying coding optimization trends
    • Provider and practice education
    • Member engagement
    • Annual visit processes and activities
    • Data-acquisition and reporting
    • Data-validation and submission
    • Integration of solutions into to replicable, operational workflow.
  • Accountable for the development, maintenance, and organizational awareness of Risk Adjustment Data Validation policies and procedures.
  • Manages cross-functional efforts related to internal and external risk adjustment data validation audits.
  • Coordinates the collection, validation, submission, reporting and reconciliation of pertinent data regarding Risk Adjustment. Coordinates seasonal RAPS and EDS audit, and implements changes based on results
  • Prepares analysis and actionable insights to drive initiatives to improve diagnosis accuracy.
  • Reports summarized findings to Senior Management, providers, practices, and other entities as required.
  • Performs in-depth and highly complex analysis to identify members/providers for program interventions, evaluate intervention results, determine trends, and forecast outcomes.
  • Serves as a subject matter expert for the organization with regards to risk adjustment.
  • Serves as a technical expert advisor and consultant to internal staff, vendor and other external entities.
  • Obtain and maintain current knowledge of:
    • The Center for Medicare and Medicaid Services (CMS)
    • hierarchical condition codes (HCCs)
    • prescription drug HCCs (RxHCCs)
    • risk adjustment values
    • ICD-9/ ICD-10, HCPCS and CPT code sets.
  • Complies with all applicable laws and regulations.
  • 3- 5 years of relevant experience in a leadership role in healthcare.
  • 2+ Years in Risk Adjustment analytics is strongly preferred
  • Prior experience with Electronic Medical Records, ECW preferred.
  • Prior experience and working knowledge of Medicare, ACA and commercial insurance is a plus
  • Expertise in Analytics, Statistics and data Visualization is required
  • Proven knowledge of Medical Coding principles is required.
  • Bilingual (English and Spanish) required
  • Advanced Excel skills are required
  • Leadership skills are a must
  • Advanced Computer skills
  • Excellent written and verbal communication
  • Problem solver, multi-tasking
  • Prior experience working in a fast-paced environment is preferred
  • Eager learner, collaborative partner
  • Attention to detail


    • Bachelor’s degree in Healthcare of related field.
    • CPMA & CRC Certifications Preferred

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