Clinical Risk Adjustment Manager

Role Overview

• 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