Risk Adjustment Program Lead
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Job Description
Risk adjustment program lead improving Medicare Advantage and ACA performance for Capital Blue Cross. Analyzing results, coordinating vendors, and driving operational initiatives.
Responsibilities:
- Analyze program results against operating plans and targets, investigate variances, and coordinate actions to address risks and opportunities
- Develop and maintain dashboards, recurring reports, performance measures, and vendor scorecards
- Validate data and metric definitions to ensure accurate, consistent, and useful reporting
- Maintain program planning inputs and assumptions, track changes, and flag issues affecting projected results
- Coordinate with Finance and Actuarial partners
- Own initiatives from initial analysis through implementation and completion
- Establish deliverables and milestones, coordinate stakeholders, track progress, address or escalate barriers, and confirm results
- Plan and facilitate program performance and workstream meetings
- Monitor vendor performance and deliverables, investigate variances, coordinate follow-up, and escalate unresolved issues
- Support vendor evaluations and proof-of-concept initiatives
- Monitor CMS and other regulatory developments, guidance, and deadlines
- Partner with Analytics, Coding, Provider Engagement, Chart Retrieval, Actuarial, Compliance, and vendors
- Prepare reports, presentations, and updates on program results, emerging issues, and recommendations
- Improve reporting processes, workflows, and tracking tools
Requirements:
- High School Diploma required
- Bachelor’s degree in business administration, Economics, Finance, Health Care, Information Systems, Public Health, Statistics, Mathematics, or a related field
- 3 years of healthcare industry work experience, or 6 years of relevant experience in lieu of degree
- 2 years of Risk Adjustment Program or Operations work experience
- Working knowledge of Medicare Advantage and ACA risk adjustment programs, operational processes, and payment methodologies
- Understanding of performance measurement, data validation, and operational reporting
- Working knowledge of financial concepts, including budgets, forecasts, and variance analysis
- Familiarity with regulatory requirements and their implications for risk adjustment operations
- Experience coordinating projects or workstreams involving multiple stakeholders and deadlines
- Proficiency in Microsoft Office applications, including advanced Excel skills
- Experience with Power BI or other business intelligence tools preferred
- Ability to independently manage assignments and initiatives
- Strong analytical, problem-solving, written, verbal communication, organization, documentation, and meeting facilitation skills
- Ability to build effective working relationships and coordinate across internal departments and external vendors
- Ability to work in an agile and dynamic environment
- Ability to occasionally lift or move up to 5 pounds
Benefits:
- Medical coverage
- Dental coverage
- Vision coverage
- Retirement Plan
- Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
- Flexible work environment
- Training and continuing education
- Community volunteering opportunities
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