Medicare Risk Adjustment Manager Job at CVS Health (Work at Home)

Director, Provider Education & Risk Adjustment

The Physician Educator serves as a liaison between the Health Plan and the parti...

Location

United States , New York

Salary:

175000.00 - 200000.00 USD / Year

MJHS

Expiration Date

Until further notice

Requirements

Bachelor's Degree required or comparable work experience will be considered
Minimum 5 years of experience in professional services, including practice management, nursing, clinical documentation improvement or quality audit
2-3 years of teaching experience in a clinical setting preferred
2-3 years of progressive leadership experience preferred
Extensive knowledge of coding and documentation requirements including ICD-10-CM, CPT-4, and HCPCS
In-depth knowledge of medical terminology, anatomy and physiology, pharmacology, and pathology required
A general understanding of Health care insurance and Medicare managed care is highly preferred for this position
Excellent verbal and written communication skills, analytical skills, and organization skills required
Extensive problem-solving experience is required
Experience working with physicians and physician practices

Job Responsibility

Develop and maintain collaborative relationships with assigned providers/practices within Elderplan Network
Coordinate and present education of providers/practices related to risk adjustment, coding, and clinical documentation improvement
Assess workflow processes in physician practices that impact the ability to maximize Health Plan revenue achieved through the various risk adjustment payment models
Identify trends and barriers that interfere with correct coding and documentation practices in the physician practice sites, including but not limited to workflow, electronic health records, and clearinghouses
Adhere to CMS coding and documentation guidelines
Analyze medical record documentation and coding through a chart review process that identifies incorrect coding, coding lacking supporting documentation, and missed opportunities to capture risk adjustment diagnoses and associated revenue
Analyze and distribute reports to providers that summarize their performance related to coding and documentation and risk adjustment
Develop and implement strategic action plans based on findings of assessment of physician practice workflows and medical record documentation reviews
Maintain confidentiality of chart review results and member information
Maintain a current and in-depth knowledge of CMS guidelines related to risk adjustment, coding, documentation, as well as knowledge of new models of risk adjustment that impact Health Plan revenue

What we offer

Tuition Reimbursement for all full and part-time staff
Generous paid time off, including your birthday
Affordable and comprehensive medical, dental and vision coverage for employee and family members
Two retirement plans! 403(b) AND Employer Paid Pension
Flexible spending
Paid Student Loan Forgiveness Program (PSLF)

Fulltime

Risk Adjustment Education Specialist

This Job will report to the Risk Adjustment Manager of Coding Operations. Respon...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Associate degree or equivalent experience required
5 years of experience in a hospital, a physician setting, or a Managed Care Organization as a medical coder required
2 years of experience in coding with knowledge of Medicare risk adjustment (HCC Coding) required
Other experience in teaching, training, or an educator/instructor role is needed
Must have experience in creating effective training materials and presentations (PowerPoint, Adobe, etc.)
Certified Professional Coder (CPC) from AAPC is required
Certified Risk Adjustment Coder (CRC) from AAPC is preferred
An RN or LVN must obtain both CPC and CRC within 12 months of hire
Must be proficient in Prospective, Retrospective, and Concurrent review processes
Must have strong clinical knowledge of disease pathology and ability to identify clinical indicators related to chronic disease

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Subject matter experts for proper risk adjustment coding and CMS data validation
Work in conjunction with other departments, including Provider Relations, Quality, and the Medical Director, to ensure compliance with CMS risk adjustment guidelines
Analyze MRA data to identify patterns and development of provider and market-level interventions to coordinate an educational work plan for providers
Conduct provider education and training regarding risk adjustment to help ensure accurate CMS payment and improve care quality
This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc
Responsible for building positive relationships with assigned Physicians and serving as a contact for any questions or concerns that may arise
Identify those Practices that need initial or ongoing additional training
Perform other duties as necessary

Fulltime

Business Analyst

Are you a healthcare data enthusiast who thrives at the intersection of operatio...

Location

United States

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Bachelor’s degree in Healthcare Administration, Business Administration, Finance, Health Informatics, or a closely related field (or equivalent specialized work experience)
Minimum of 2+ years of hands-on data analytics experience within the healthcare field
Strong operational familiarity with Medicare Advantage, Managed Care, Capitation models, and medical group structures (clinical operations, care management)
A self-starter with an elite sense of personal accountability and a passion for owning projects in a fast-paced, high-energy environment
Expert-level spreadsheet management and financial/operational modeling
Must easily manipulate large volumes of data, build advanced pivot tables, and use complex formulas (INDEX/MATCH, XLOOKUP, nested IF statements, etc.)
Expert proficiency in SQL or MS Access to query, filter, and extract data from data warehouses or Electronic Health Records (EHR)
Hands-on experience utilizing Microsoft Visio to map out complex, multi-layered workflows, swimlane diagrams, and operational bottlenecks

Job Responsibility

Complete routine and complex data analysis projects, process mapping, and workflow modeling
Identify variances, performance trends, and anomalies within Risk Adjustment and clinical documentation datasets
Conduct end-to-end business process assessments across coding operations and CHAPs workflows
Formulate data-driven strategies, tactics, and solutions to eliminate process bottlenecks
Prepare, maintain, and expand a dynamic library of key performance measures, dashboards, and automated operational reports
Manage recurring scheduled reports while balancing concurrent ad hoc project requests
Act as an embedded analytical partner to Department Heads, Clinical Leaders, and Matrixed Operations teams to drive strategic market initiatives to completion
Ensure absolute data integrity and regulatory alignment with CMS guidelines
Protect and disclose patients’ protected health information (PHI) in strict compliance with HIPAA standards

What we offer

Medical, vision, dental, and life and disability insurance
401(k) plan

Revenue Cycle Management Specialist

We are looking for a Revenue Cycle Management Specialist to join a healthcare or...

Location

United States , Chicago

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

At least 3 years of experience in healthcare revenue cycle, medical billing, or claims management
Hands-on knowledge of Medicare and Medicaid billing practices, including claim review, submission, and follow-up
Familiarity with CMS regulations, reimbursement methodologies, and healthcare audit expectations
Experience resolving denied or underpaid medical claims and improving billing accuracy
Understanding of revenue cycle processes across charge capture, claims processing, and payment reconciliation
Background working in an FQHC or similar healthcare setting is strongly preferred
Strong analytical skills with the ability to identify process gaps and support compliance-focused billing operations

Job Responsibility

Manage day-to-day revenue cycle activities, including charge review, claim submission, payment posting, denial follow-up, and account resolution
Prepare and submit accurate medical claims for Medicare, Medicaid, and other applicable payers while ensuring timely reimbursement
Investigate billing discrepancies and denied claims, identify root causes, and take corrective action to reduce payment delays
Conduct audits of billing and reimbursement activity to confirm alignment with CMS guidelines and internal compliance standards
Monitor revenue cycle performance trends and recommend process improvements that support cleaner claims and stronger collections
Collaborate with clinical, administrative, and finance teams to resolve account issues and maintain accurate documentation for billing purposes
Support billing operations within an FQHC environment, including payer-specific requirements related to Medicare and Medicaid programs
Maintain current knowledge of reimbursement regulations, risk adjustment considerations, and evolving government payer requirements

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

Senior Project Manager

We are looking for a Senior Project Manager to lead complex, enterprise-level in...

Location

United States , Minnetonka

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Demonstrated experience managing complex transformation or operational initiatives in a healthcare or payer environment
Working knowledge of Medicare, HealthCare.gov, risk adjustment, or related regulated healthcare programs is preferred
Proven ability to lead projects involving multiple departments, senior stakeholders, and high-visibility business objectives
Strong skills in project planning, timeline management, dependency coordination, and issue resolution
Experience with financial oversight, including budgeting, cost tracking, and analysis of project expenditures
Excellent communication and leadership abilities, with the confidence to influence teams and support executive-level discussions
Self-directed approach with a strong sense of ownership, sound judgment, and the ability to move work forward with minimal supervision

Job Responsibility

Direct large-scale, cross-functional projects from initiation through completion, ensuring schedules, budgets, and deliverables remain on track
Work closely with business, technology, and product leaders to clarify objectives, define milestones, and align project outcomes with organizational priorities
Assess staffing needs, coordinate resource planning, and collaborate with leadership to address capacity gaps throughout the project lifecycle
Build and maintain detailed project roadmaps, including critical milestones and dependencies, and adjust plans as priorities or business decisions evolve
Monitor project health by tracking risks, issues, and interdependencies, while driving timely resolution and escalating concerns when needed
Facilitate coordination across operational, technical, and business readiness activities to keep implementation efforts synchronized
Provide clear status updates and executive-level reporting to key stakeholders, including senior leadership and governance groups
Oversee project-related financial activity, including budget tracking, expenditure review, and partnership with finance or program leadership to resolve variances

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

Senior Healthcare Informatics Analyst - Pharmacy

The Senior Healthcare Informatics Analyst – Pharmacy Analytics role focuses on p...

Location

United States , Baton Rouge

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

4 years of healthcare analytics experience, with pharmacy or PBM analytics experience strongly preferred
3 years experience analyzing pharmacy claims, formulary performance, drug mix, utilization trends, rebates, and adherence metrics (PDC/MPR)
2 years experience/advanced knowledge of SAS (including Enterprise Miner) preferred
3 years experience with SQL, SAS, R, Python, Tableau, or similar analytic/visualization tools
Bachelors degree in healthcare administration, pharmacy, public health, statistics, economics, analytics, computer science, or related field required
Masters degree in a related field preferred
Strong critical thinking, analytical, and problem-solving skills
Experience building predictive and explanatory models related to pharmacy utilization, cost, and outcomes
Knowledge of pharmacy outcomes research, utilization management, and drug trend analysis preferred
Strong working knowledge of the U.S. healthcare system in a payer setting, with specific understanding of pharmacy benefits and PBM operations

Job Responsibility

Leads the selection and application of pharmacy-focused analytic, evaluation, and BI methodologies to support business decisions and strategic planning
Leverages pharmacy claims data, PBM feeds, EDW data sources, and non-EDW datasets to deliver actionable insights
Independently partners with business teams to define pharmacy analytics needs and develop solutions such as predictive models, dashboards, utilization analyses, and performance metrics
Serves as a pharmacy analytics advisor on enterprise and cross-functional initiatives
Translates pharmacy business rules and policies into analytical models and reporting solutions, acting as a liaison between Pharmacy, Analytics, IT, and EIM teams
Performs peer data quality reviews to ensure accuracy, completeness, and consistency of pharmacy analytics output
Conducts advanced descriptive and statistical analyses related to drug utilization, adherence, cost drivers, and clinical outcomes

Sr. Manager, APM Modeling & Analytics

Arcadia is expanding its leadership in advanced alternative payment models (APMs...

Location

United States

Salary:

Not provided

The Muse

Expiration Date

Until further notice

Requirements

Bachelor's Degree in related Data Science, Actuarial Science, Finance, Economics or related field
Minimum of 6 years of healthcare experience, with a focus on CMS APMs, value-based contracting and analytics
Strong accountability, intellectual curiosity, and customer satisfaction mindset
Experience modeling and evaluating key financial parameters within value-based contracts for health plan or provider
Experience with database querying (SAS, SQL, Python), Amazon Quick Site or BI Tool equivalent

Job Responsibility

Own end-to-end financial modeling for CMS LEAD and other APMs
Translate CMS technical specifications into production-grade actuarial models
Develop and maintain benchmark, attribution, risk adjustment, and reconciliation logic
Ensure integrity of actuarial inputs (e.g., underwriting methodology, pricing assumptions) in value-based contract modeling
Identify model vulnerabilities and proactively mitigate financial exposure
Work directly with CMS VRDC data environments to extract, structure, and analyze Medicare claims and enrollment data
Write production-level SAS and Python code to process large claims datasets, facilitate risk-adjustments, calculate, risk adjust, and project PMPM benchmarks, run sensitivity testing, conduct reconciliation and true-up calculations
Ensure compliance with CMS methodological guidance
Validate data integrity prior to model production
Establish independent validation standards and ensure consistent adherence to these standards across the enterprise

What we offer

Pet Insurance
Health Insurance
Dental Insurance
Vision Insurance
FSA
HSA
HSA With Employer Contribution
Life Insurance
Short-Term Disability
Long-Term Disability

Network Management Consultant

The Network Management Consultant supports the Senior Manager in advancing provi...

Location

United States , Chicago

Salary:

55900.00 - 123500.00 USD / Year

Health Care Service Corporation

Expiration Date

Until further notice

Requirements

Bachelor’s Degree and at least one year experience developing and negotiating provider contracts OR 5 years managed care operations experience handling independent work with at least one year experience developing and negotiating provider contracts
Meet deadlines and work well under pressure
Verbal and written communication skills, organizational and planning skills
PC proficiency to include Microsoft Office
Analytical skills
Ability and willingness to travel within assigned territory, including overnight stays

Job Responsibility

Supports the Senior Manager in advancing provider network performance across Medicare Advantage markets with a focus on quality improvement, risk adjustment optimization, and value-based care initiatives
Collaborates with internal teams and external provider partners to implement strategies that improve clinical quality outcomes, coding accuracy, and overall network performance
Assists in provider engagement, performance analysis, and operational execution of programs that support risk capture, quality ratings, and regulatory compliance within the Medicare Advantage line of business

What we offer

Curated development plans that foster growth and promote rewarding, fulfilling careers
Investment in professional development

Fulltime

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Medicare Risk Adjustment Manager

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