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Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in risk adjustment initiatives, project management, and cross-functional collaboration within healthcare environments. Proficient in translating complex data into actionable insights while ensuring compliance with CMS guidelines and coding standards.
Highest-signal resume keywords
Risk Adjustment ExperienceProject ManagementActive Coding CertificationCross-Functional CollaborationAnalytical Skills
About the role
Key responsibilities & impact- Deliver risk adjustment initiatives and priorities for assigned clients or markets
- Translate risk adjustment plans into structured workplans with milestones, owners, timelines, and dependencies
- Maintain project trackers and follow-up cadence through completion and measurable results
- Coordinate with clinical, operational, coding, analytics, and provider-facing teams
- Identify barriers and opportunities and escalate issues appropriately
- Provide status updates to the Director, including delays, risks, and required decisions
- Support the end-to-end risk adjustment continuum, including attribution, access, suspecting, gap analysis, point-of-care support, documentation, coding, retrospective review, submission, reconciliation, and audit readiness
- Apply knowledge of Medicare Advantage, ACA/commercial, MSSP/ACO, Medicaid, and other value-based care models
- Identify opportunities to improve accurate condition capture and recapture
- Trace diagnoses from documentation through coding, submission, acceptance, and payer credit; resolve breakdowns
- Interpret reporting and identify performance opportunities
- Evaluate risk adjustment activity, trends, gaps, and outcomes
- Connect performance to clinical accuracy, RAF/MLR, financial impact, and operational results
- Present market performance updates and recommendations to leadership
- Build relationships with physicians, client leadership, coding, analytics, and provider-facing teams
- Translate coding and documentation findings into practical guidance and education priorities
- Influence process and behavior changes through collaboration and recommendations
- Advise on workflow design, documentation practices, and process changes
- Develop reusable tools, trackers, educational materials, and processes
- Identify opportunities to use AI-enabled tools and automation
- Support compliance with CMS guidance, coding requirements, organizational standards, RADV, and other audit readiness activities
- Monitor performance, intervention effectiveness, opportunity conversion, cost per chart, and provider burden
- Share lessons learned and successful practices with relevant teams
Requirements
What you’ll need- Bachelor's degree in healthcare, business, health information management, or related field; equivalent experience may be considered
- 5+ years of risk adjustment experience, including project leadership and direct interaction with providers, clients, or market stakeholders
- Experience in a provider, payer, or health plan environment; experience in both is preferred
- Experience with CMS-HCC V28 and multiple lines of business, such as Medicare Advantage, ACA/commercial, MSSP/ACO, or Medicaid
- Experience with prospective, concurrent, and retrospective risk adjustment
- Experience partnering with analytics, coding, clinical, operational, and provider-facing teams
- Experience leading multiple priorities and influencing change without direct authority
- Demonstrated experience managing cross-functional projects from planning through completion
- Active coding certification required (CRC preferred; CPC, CCS, or equivalent accepted)
- Strong knowledge of risk adjustment, CMS requirements, coding guidelines, and audit standards
- Strong analytical, critical-thinking, and problem-solving skills
- Ability to translate complex data into clear business recommendations
- Strong project management and organizational skills
- Strong provider engagement and relationship-building skills
- Excellent written, verbal, presentation, and executive communication skills
- Ability to influence and collaborate across a complex organization
- Ability to balance enterprise standards with client-specific needs
- Proficiency with Microsoft Office and spreadsheet-based analysis
- Comfortable using AI-enabled tools to improve productivity and workflow efficiency
- Ability to travel approximately 20% annually
Benefits
Comp & perks- Medical, Dental, Vision, Life, Long/Short Term Disability
- Health Savings Account/Flexible Spending Account
- Fraud Protection
- Legal, Pet and other fringe benefits
- Generous PTO policy
- 9 paid holidays
- 401k match
- Profit sharing
- Tuition reimbursement
- Wellness program
- Opportunities for professional growth and mentorship
- Emphasis on work-life balance
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Risk AdjustmentProject LeadershipCoding GuidelinesData AnalysisPerformance MonitoringGap AnalysisDocumentation PracticesAudit ReadinessCondition CaptureHealthcare Compliance
Soft Skills
Relationship BuildingInfluencing ChangeCritical ThinkingCommunication SkillsProblem Solving
Tools & Technologies
Microsoft OfficeSpreadsheet AnalysisAI-Enabled ToolsProject TrackersEducational Materials
Certifications & Qualifications
Active Coding CertificationCRCCPCCCS
Industry Keywords
Medicare AdvantageACAMSSPACOMedicaidCMS-HCC V28Value-Based CareHealthcare ManagementPayer EnvironmentProvider Engagement