Manager, Risk Adjustment Quality Assurance
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AI Summary
This role manages the prospective, concurrent, and retrospective risk adjustment internal audit and education functions, providing leadership for teams auditing HCC capture, clinical validation, and documentation compliance across the risk adjustment lifecycle. Key duties include managing audit staff, establishing standardized audit frameworks, overseeing various chart audits, and developing quality assurance programs.
Job Description Summary
Position SummaryThe Manager of Burden of Illness Quality Assurance oversees the prospective, concurrent, and retrospective risk adjustment internal audit and education functions. This role provides strategic and operational leadership for teams responsible for auditing HCC capture, clinical validation, and documentation compliance across the full risk adjustment lifecycle. The Manager ensures consistent audit methodology, regulatory compliance, staff development, and performance improvement, while serving as a subject-matter leader for CMS and HHS risk adjustment models.
How will you make an impact & Requirements
Key Responsibilities
Leadership & Team Management
- Directly manage and develop internal auditors and educators supporting prospective, concurrent, and retrospective risk adjustment workflows.
- Establish standardized audit frameworks, scoring methodologies, and inter-rater reliability processes across all review types.
- Set performance expectations, conduct evaluations, and implement competency and career development plans.
- Lead hiring, onboarding, training, and succession planning for audit and education staff.
Education & Program Development
- Oversee prospective chart scrub audits, concurrent HCC validation and gap capture audits, and retrospective rejection/validation audits.
- Ensure audits align with CMS risk adjustment regulations, ICD-10-CM Official Guidelines, and organizational compliance standards.
- Develop and maintain audit policies, procedures, and quality assurance programs.
Quality Improvement
- Establish KPIs and dashboards for prospective, concurrent, and retrospective audit programs.
- Analyze trends in missed HCCs, unsupported diagnoses, rejection rates, and documentation gaps.
- Drive continuous improvement initiatives to enhance accuracy, completeness, and financial integrity.
Qualifications
Required
- Bachelor’s degree or equivalent work experience
- Active credential: CRC, CPC, CPMA, or similar certification
- 5+ years of risk adjustment coding and/or auditing experience
- Strong knowledge of CMS-HCC models, ICD-10-CM, MEAT, and audit methodology
- Experience providing education or training to internal coding teams
- Excellent written and verbal communication skills
- Strong analytical and reporting skills
- Ability to work independently in a fast-paced, cross-functional environment
Key Competencies
- Regulatory and compliance expertise
- Attention to detail and critical thinking
- Professional communication and presentation skills
- Ability to translate complex coding rules into practical guidance
- Collaborative, consultative approach
Key Responsibilities
Leadership & Team Management
- Directly manage and develop internal auditors and educators supporting prospective, concurrent, and retrospective risk adjustment workflows.
- Establish standardized audit frameworks, scoring methodologies, and inter-rater reliability processes across all review types.
- Set performance expectations, conduct evaluations, and implement competency and career development plans.
- Lead hiring, onboarding, training, and succession planning for audit and education staff.
Education & Program Development
- Oversee prospective chart scrub audits, concurrent HCC validation and gap capture audits, and retrospective rejection/validation audits.
- Ensure audits align with CMS risk adjustment regulations, ICD-10-CM Official Guidelines, and organizational compliance standards.
- Develop and maintain audit policies, procedures, and quality assurance programs.
Quality Improvement
- Establish KPIs and dashboards for prospective, concurrent, and retrospective audit programs.
- Analyze trends in missed HCCs, unsupported diagnoses, rejection rates, and documentation gaps.
- Drive continuous improvement initiatives to enhance accuracy, completeness, and financial integrity.
Qualifications
Required
- Bachelor’s degree or equivalent work experience
- Active credential: CRC, CPC, CPMA, or similar certification
- 5+ years of risk adjustment coding and/or auditing experience
- Strong knowledge of CMS-HCC models, ICD-10-CM, MEAT, and audit methodology
- Experience providing education or training to internal coding teams
- Excellent written and verbal communication skills
- Strong analytical and reporting skills
- Ability to work independently in a fast-paced, cross-functional environment
Key Competencies
- Regulatory and compliance expertise
- Attention to detail and critical thinking
- Professional communication and presentation skills
- Ability to translate complex coding rules into practical guidance
- Collaborative, consultative approach
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