Sr Mgr Risk Adjustment Audit

• What Is your Impact?

The Sr. Manager of Risk Adjustment Audit leads the Audit team to ensure compliance with CMS and HHS risk adjustment data submission activities, supporting accurate medical record documentation, claim, pharmacy, and enrollment data transmission. This role is critical to risk score accuracy and revenue payment. The Sr. Manager will lead the Risk Adjustment Audit Team to support Medicare Advantage and/or Commercial (ACA) lines of business, overseeing development of reporting and corrective action plans related to risk adjustment audit findings, identifying, and addressing issues or trends, and developing internal control structures to mitigate risk adjustment program-related risks. Additionally, the Sr. Manager will collaborate with organizational leaders, regulatory agency personnel, and key stakeholders to manage annual risk adjustment validation audits.

***We are interested in every qualified applicant who is eligible to work for any company in the United States. However, we are not able to sponsor any VISAs currently or in the future.***

The Key Responsibilities:

• STRATEGIC FUNCTIONS:
  
  
  
  • Ensure the Risk Adjustment department's business strategies align with corporate direction and objectives.
  • Develop and implement strategic plans, translating business strategy into actionable steps and mitigating risks.
  • Build and maintain strong relationships with internal and external partners to influence strategic direction.
  • Communicate and align departmental expectations, audit activities, and operational priorities.
  
  
• MANAGEMENT OVERSIGHT:
  
  
  
  • Lead the Risk Adjustment Audit team by coaching, motivating, and developing resources to meet operational goals and drive cultural change.
  • Monitor team production standards, address performance issues, and provide ICD-10 coding guidance.
  • Collaborate with the Coding Instructor to ensure accurate ICD-10 coding and promote a culture of excellence.
  • Foster a learning environment that supports development, personal growth, and increased responsibility.
  • Anticipate and adapt to changing processes and priorities, supporting leaders in setting new goals.
  
  
• GOVERNMENT REGULATORY OVERSIGHT:
  
  
  
  • Utilize knowledge of CMS and HHS regulations to execute audit procedures, analyze results, and document findings for risk adjustment data validation audits.
  • Lead coding and medical documentation compliance audits to support vendor and provider performance management.
  • Maintain relationships with audit customers, identify risks, and assist in developing audit procedures.
  • Ensure risk adjustment controls are in place to optimize operational effectiveness and meet CMS and HHS regulations.
  • Analyze performance results to improve efficiencies and guide department policies, guidelines, and procedures.
  • Manage external audits from federal government agencies related to risk adjustment data validation.
  
  
• PROCESS IMPROVEMENTS:
  
  
  
  • Foster a culture of continuous improvement, creativity, and innovation within the Risk Adjustment Audit department.
  • Coach team members on identifying root causes and developing improvement action plans.
  • Identify and implement process improvements to enhance accuracy of CMS and HHS submission data.
  • Evaluate opportunities for automation and streamlining processes to increase efficiency.
  • Encourage new ideas and approaches and provide feedback to drive further improvements.
  • Take action on complex topics with organization-wide impact, modifying business processes as necessary.
  
  
• COLLABORATION:
  
  
  
  • Build strong relationships across business sectors and organization boundaries to meet objectives and resolve issues.
  • Foster partnerships with outsourced services (e.g., vendors, providers, and partners) to ensure process alignment and issue resolution.
  • Collaborate with peers, colleagues, and leaders to improve CMS and HHS reimbursement revenue through data validation.
  
  

What Is REQUIRED:

• 6+ years related work experience to include Health Plan risk adjustment operational activities, medical record diagnosis coding, ICD-10 coding, medical record auditing, medical record documentation education, or other related work experience
• 3+ years direct supervisory/management experience
• Related bachelor's degree or additional related equivalent work experience Healthcare Administration, Finance, Business, or another related field
  
  

Required Licenses and Certifications:

• At least one of the following: CPC (Certified Professional Code from AAPC) or COC (Certified Outpatient Coder from AAPC) or CIC (Certified Inpatient Coder from AAPC) or CCS (Certified Coding Specialist from AHIMA) or CCS-P (Certified Coding Specialists Physician Based from AHIMA) Upon Hire
• Certified Risk Adjustment Coder (CRC) designation Upon Hire
  
  

Additional Required Qualifications:

• Experience in healthcare/managed care operations, Medicare Advantage, Affordable Care Act (ACA and CMS / HHS risk adjustment
• Knowledge of and ability to coach management team on the following service tools, processes and programs: CMS and HHS regulatory requirements and reimbursement methodologies
• Demonstrated experience in coding, chart review, and data validation
• Writing skills (composes complex written arguments that influence outcomes)
• Presentation skills (presenting complex and technical information to audiences with diverse knowledge base)

Preferred Qualifications:

• Master's degree Healthcare Administration, Finance, Business, or another related field
• Demonstrated Florida Blue product knowledge
• Knowledge of over Medicare Advantage and Commercial ACA products
• Demonstrated understanding of reform and CMS and HHS compliance standards
• Demonstrated knowledge of Centers for Medicare and Medicaid Services (CMS) and Health & Human Services (HHS) Reimbursement and Risk Adjustment Programs

Preferred Licenses and Certifications:

• PMP - Project Management Professional
  
  

General Physical Demands:

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities:

Must be able to occasionally travel to multiple locations for work (i.e., travel to attend meetings, events, conferences).

What We Offer:

As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life, and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

Salary Information:

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Annualized Hiring Range: $88,100 - $110,100 (This is the budgeted and set hiring range for this specific position)

Annualized Salary Range: $88,100 - $143,100 (This is to show the long-term financial growth and maximum salary cap for this specific role)

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.