Manager, Risk Adjustment

Date: Sep 14, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5827 


Position Summary/Position


Under the direction of the Director of Quality Informatics, this position is responsible for developing strategies for successful risk adjustment data validations and enforcing coding standards based on guidelines provided by CMS for risk adjustment. The Risk Adjustment Manager is responsible for creating tools and training materials to ensure the success of risk adjustment initiatives and programs. The Risk Adjustment Manager is responsible for supporting all Risk Adjustment Data Validation (RADV) related programs and conducting analytical studies that ensure accuracy and completeness of data submitted to CMS. The Risk Adjustment Manager is responsible for supporting mock CMS RADV and assisting the team with chart review efforts and project management. The Risk Adjustment Manager works collaboratively with internal and external teams to achieve the goals and objectives as it relates to data validation activities.

Major Functions (Duties and Responsibilities)


1. Actively monitor the daily operations of all aspects of RADV related activities, including, but not limited to: creating criteria for ongoing claims data validation, conducting mock RADV and creating a readiness plan for CMS National or Contract Level RADV
2. Develop  and implement processes and procedures to ensure accuracy, completeness, and compliance with CMS regulations and guidelines for risk adjustment
3. Evaluate results from RADV activities to address barriers, gaps, opportunities for improvement, and implement corrective action plans as necessary
4. Validate deletion or addition of diagnoses codes based on medical record review
5. Identify opportunities for data mining to ensure data or coding gaps are minimized
6. Apply best practices to ensure accuracy of risk adjustment payment
7. Monitor team progress and productivity - focuses on risk score improvement, not charts touched
8. Ensure the team goals, objectives, milestones and deliverables are met in a timely manner
9. Acts as a RADV liaison with other departments, health plans, and external vendors
10. Understand and oversee RAPS and EDPS data transmission and assist in identification of issues that impact data integrity and accuracy.
11. Maintain appropriate tools, methods, and processes that mitigate potential financial risks to IEHP from errors or audit failures of risk adjustment diagnoses and supporting documents.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications


Minimum of 3 years of Management experience. Experience working in risk adjustment division in the healthcare industry. Must have direct experience with risk adjustment data validations. CMS Risk Adjustment experience required.

Preferred Experience

Education Qualifications


Bachelor’s degree in nursing, healthcare administration or related field from an accredited institution required.  

Preferred Education

Professional Certification


Active CCS, CCS-P or CPC credential required. CRC certification preferred.

Professional Licenses

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Must have expert fluency and proficiency with CMS Risk Adjustment Methodology and HCC terminology.

Skills Requirement

Abilities Requirement

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Word processing involving computer keyboard and screens, automobile travel within the Inland Empire.

Physical Requirements


Starting Salary: $111,550.40  - $142,230.40  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles