Risk Adjustment Job Description

Risk Adjustment Job Description

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Risk adjustment provides support to Risk Adjustment team members for medical claims related questions and reporting.

Risk Adjustment Duties & Responsibilities

To write an effective risk adjustment job description, begin by listing detailed duties, responsibilities and expectations. We have included risk adjustment job description templates that you can modify and use.

Sample responsibilities for this position include:

Serve as a Subject Matter Expert and resource in Clinical Documentation
Effectively track and monitor programs
Communicate expectations with team members and other stakeholders
Create, maintain and optimize SAS programs
Perform risk adjustment data analysis
Administer provider incentive and provider reimbursement programs
Monitor medical records review activities
Coordinate charts retrieval process across hospitals and provider groups
Work with vendors and internal subject matter experts
Establish and maintain key metrics showing risk adjustment program effectiveness

Risk Adjustment Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Risk Adjustment

List any licenses or certifications required by the position: CRC, AAPC, AHIMA, SAS, CPC, CCS, RHIT, PMP, SQL, CCA

Education for Risk Adjustment

Typically a job would require a certain level of education.

Employers hiring for the risk adjustment job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Healthcare, Finance, Health, Business, Computer Science, Medical, Healthcare Administration, Health Administration, Math

Skills for Risk Adjustment

Desired skills for risk adjustment include:

EMR for recording patient visits
Medical terminology
ICD10
Billing/claims submission and other related actions
Excel
Medicare risk adjustment
Pharmacology
Disease processes
Medical and clinical terminology
Clinical documentation

Desired experience for risk adjustment includes:

Bachelor’s degree required, with a preference for a degree in Finance/Accounting/Applied Math/Statistics, with preference for an MBA/MHA
Strong knowledge of ICD 9 and ICD 10 codes
Progressive work experience in the Healthcare industry
Ability to travel around 30% over the central and southern Florida area
Medical provider education experience
Experience with reporting/business intelligence tools against large databases, such as SAS, SSRS and Access

Risk Adjustment Examples

1

Risk Adjustment Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of risk adjustment. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for risk adjustment
  • Communicate with physicians and office staff on records needed for chart reviews
  • Perform chart reviews for appropriateness and completeness of diagnostic codes based on CMS HCC categories
  • Perform quality check on charts coded by vendor
  • Collaborate in the development of coding or risk adjustment tools/training aides for contracted providers and staff
  • Maintain all record lists of members and providers for Chart Retrieval and Coding
  • Schedule appointments with providers and practices for chart retrieval
  • Pickup, organize and copy/scan charts retrieved from providers and practices
  • Collaborates with members to ensure appropriate data understanding and use
  • Manage daily operations of multiple levels of staff and multiple functions / departments across business units
  • Management leadership internal and external to the organization
Qualifications for risk adjustment
  • Comprehensive understanding of HCC coding rules, regulations and methodology
  • CCS or CPC Coding Certification through AHIMA/AAPC
  • Experience in customer service and or telephonic role
  • Accountable for financial and non-financial results (budget and actuals)
  • 3+ years of risk adjustment experience with expertise in lines of business and / or risk adjustment functional areas
  • Intermediate level knowledge of CMS submission requirements
2

Risk Adjustment Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of risk adjustment. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for risk adjustment
  • Follow up with providers as necessary
  • Coordinate with internal departments and vendors
  • Ensure timely completion of medical record request to meet departmental goals and CMS deadlines
  • Interface via phone, fax and mail with providers and contracted vendors
  • Supports quality improvement interventions by collecting medical records data
  • Data extraction, financial reconciliation, and analytics
  • Participate in discussions with respect to ongoing projects
  • Construction of models to support key business functions
  • Production and presentation of results to senior leaders
  • Perform ad hoc analysis for multiple product lines
Qualifications for risk adjustment
  • Multi-tasking, ability to manage at macro level and also dig deep into issues for successful resolution
  • E / M Training, coding certification (AAPC)
  • Expert knowledge of Medicare severity adjustment processes and tools
  • 3+ years risk adjustment experience with expertise in lines of business and/or risk adjustment functional areas
  • Cultivate internal and external business relationships that will serve as resources of technical knowledge and performance improvement
  • Coding Certification required (CPC, CCS, CCS-P, or RHIT
3

Risk Adjustment Job Description

Job Description Example
Our company is looking for a risk adjustment. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for risk adjustment
  • Synthesize competitive analysis and market assessments to establish go-to-market strategies that capitalize on market trends, customer needs and competitive positioning
  • Establishes Strategic Product Roadmaps for market offerings, including, developing new products, expanding on existing solutions, and leveraging existing products to build platform-based solutions
  • Owns the operational calendar of the product strategy and engages the Portfolio Manager and / or the Product Manager to create Strategic Product Roadmaps
  • Segments markets, identifies target customers and uncovers market needs
  • Responsible for go to market strategy, value proposition definition and key differentiation messaging
  • Constantly collect and analyze performance data (e.g., market, financial, and operational) in order to identify new opportunities for the business
  • This role reports to the VP of Strategic Product Management
  • Ensure team has appropriate staffing and skill sets to conduct investigations
  • Provide leadership for key initiatives risk adjustment initiatives
  • Oversee, coordinate, or perform data mining and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine annual risk adjustment program strategies to achieve optimal performance
Qualifications for risk adjustment
  • 5 or more years of experience successfully managing and leading functional teams with educational, reporting, compliance and documentation responsibilities
  • Demonstrated capability to work cross functionally within corporate matrix environments, confirmed by references who will speak to effective collaboration and partnership on complicated initiatives
  • Knowledge of HIPAA 837 and 835 electronic claims transactions
  • 1+years of experience working with Risk Adjustment in Medicare Advantage, Medicaid, and/or ACA
  • Minimum two (2) years of comparable experience required
  • Basic knowledge of PC-based query and report writing tools such as MS Access or Crystal Reports
4

Risk Adjustment Job Description

Job Description Example
Our company is looking for a risk adjustment. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for risk adjustment
  • Analyze business process information (e.g., metrics
  • Provide guidance and support related to CDOs as needed by individual markets
  • Lead Product, service or process decisions that are most likely to impact multiple groups of employees and/or customers (internal or external)
  • Coordinate training network provider and staff training required to address knowledge gaps and new HCC/diagnoses identified as opportunities
  • Develop and maintain an expert level of knowledge of Medicare and risk-based reimbursement methodologies
  • Makes recommendations to Clinic Administrators/Physicians as to how to best support the HCC/RAF optimization strategies
  • Develop and strengthen relationships with provider partners to achieve improvements in risk adjustment program participation and data validation
  • Oversee and improve the processes that capture encounter data and ensure appropriate submission to CMS
  • Develop forecasting methodologies that translate data mining initiatives (coded data) into revenue estimations for annual budgeting process
  • Present HCC/RAF performance results and findings regularly to physicians and clinic administrators, including the overall HCC/RAF score, improvement strategies and tactics
Qualifications for risk adjustment
  • Requires strong communication skills, ability to keep up with technological changes, techniques and improvements, and apply those to current environment, strong customer service focus, and organizational and time management skills
  • Exposure to reporting from large databases or data warehouses and some understanding of the data relationships within these
  • Knowledge of Internet, Intranet, mainframe, and PC environments
  • Proven ability to work with customers to understand business requirements and translate those needs into a final product
  • Requires an understanding of data available in the company, an understanding of the business requirements, and the creativity to develop workable solutions for a wide range of customers
  • Familiarity with SQL and Visual Basic preferred
5

Risk Adjustment Job Description

Job Description Example
Our company is growing rapidly and is looking for a risk adjustment. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for risk adjustment
  • Leading and supporting various Risk Adjustment initiatives such as expansion of screening clinic to additional locations and more broad deployment of screening equipment in contracted physician offices
  • Reporting of organizations performance on key metrics to all management levels
  • Ability to recognize ideas / initiatives to help the organization reach year end goals and communicate the downstream analysis of the idea/initiative
  • Maintains current knowledge of CMS-HCC and CDPS risk adjustment policies, procedures and best practices
  • Support Physician Education efforts on CMS-HCC risk adjustment model, CDPS risk adjustment model, how to utilize available reports and tools, and other related projects and initiatives
  • Independently, or as directed, research complex coding HCC issues and keep abreast of coding and compliance changes as communicated by CMS, HHS, AHA, AMA, and the Federal Register pertaining to Risk Adjustment
  • Researchs, validates, and analyzes data for monitoring and reporting, strategic & tactical support, and research & development projects
  • Prepares reports and exhibits
  • Recommends new ways of performing work tasks or projects, applying research and/or additional benchmarks to generate solutions
  • Research, analyze, maintain, modify, validate and prepare data for Provider Reimbursement Program (PRP) for Medicare Advantage or Commercial ACA business, with adherence to CMS and internal timelines
Qualifications for risk adjustment
  • Experience setting new policies and procedures into opractice specifically working with Risk Adjustment Factors and/or Healthcare coding practices
  • In pursuit of a bachelor degree in finance, actuarial science, economics, mathematics or another applicable field of study
  • Previous experience in informatics or analytics and working with large data sets
  • Intermediate level proficiency with Access, SQL and / or other database programs
  • Previous experience creating dashboards and / or executive summaries
  • Previous experience in informatics or analytics and working with large data sets with healthcare data

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