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Job Summary
The Manager, Risk Mitigation is the thought leader role responsible for the design, implementation, and execution of auditing programs ensuring the accuracy, compliance, and integrity of risk adjustment processes. This role mitigates financial, operational and compliance risks through proactive audits, data validation, internal controls oversight and cross-functional collaboration. This leader initiates and implements overall strategic direction set by the VP and Director of Prospective Operations and Risk Mitigation, as well as other Directors of Risk Adjustment.
The role is responsible for helping to achieve the risk adjustment program vision, strategies, objectives, and goals. This includes leading a team responsible for ensuring the accuracy, compliance, and integrity of all risk adjustment coding and documentation reviews both retrospectively and prospectively for the Health Plan. Additionally, the Risk Mitigation Manager is responsible for monitoring targets; leading teams in analyzing, reporting, and forecasting key risk adjustment metrics; managing risk adjustment vendors; as well as, ensuring new legislation and regulations regarding risk adjustment are properly understood and accounted for.
Lastly, the role directly supports the Director Prospective Operations and Risk Mitigation in identifying, developing, promoting and executing process improvement strategies and priorities to reduce redundancies, ensure maximum efficiencies, align with other Priority Health systems and processes, as well as to ensure appropriate policies and procedures exist.
Essential Functions
- Manages the daily workflow of Risk Mitigation Team which includes managing the full lifecycle of retrospective coding audits, prospective documentation and coding reviews, vendor audit oversight, RADV, IPM, OIG, IVA, and other regulatory audits. Follows the strategic direction and implements risk adjustment initiatives required to achieve the business goals and objectives. Assists leadership in identifying, assessing and prioritizing risks related to coding, data accuracy, provider documentation and compliance with CMS/HHS requirements. Develops and implements risk mitigation strategies and process improvements to reduce audit exposure. Draft actionable audit observations & recommendations to strengthen controls and reduce compliance risk.
- Responsible for monitoring and managing Risk Mitigation staff quality and productivity by conducting regular 1:1s, performance evaluations, calibration sessions, and competency assessments to ensure quality and accuracy requirements are being met. Additionally, set and manage productivity and quality benchmarks by chart type and coder level. Provide a summary of productivity and quality findings on a regular cadence, and provide coaching and feedback on achieving production and quality standards of the role. Ensures high-quality, on-time audit deliverables.
- Establish and/or update policies and procedures as necessary to ensure coding accuracy and productivity, improve efficiencies, and minimize risk in audits for the health plan and ensuring accurate risk score capture. Monitor risk adjustment performance indicators such as RAF accuracy, prevalence rates and audit error rates. Ensure adherence to CMS, HHS, and state specific risk adjustment regulations by maintaining expert level knowledge of existing HCC models (both medical & Rx for all applicable LOB) and maintaining knowledge of model changes, coding guideline updates, and RADV requirements, serving the organization as the SME. Identify compliance risks and establish and implement corrective action plans under the supervision of the Director of Prospective Operations and Risk Mitigation.
- Responsible for the development of actionable training materials, onboarding materials, reporting metrics, including scorecards for both internal and external stakeholders. Analyze error patterns and trends to aid in the development of training materials. Motivate team members through effective training, supplemental materials and coaching to improve quality and production.
- Communicate Risk Adjustment program to internal & external audiences so they understand program objectives, goals, benefits, risks, regulations, and requirements for risk adjustment. This includes presenting operational and compliance metrics to leadership with clear recommendations. Coordinate with external vendors supporting chart review, data validation, HCC analytics and RADV preparation.
- Partner with business owners from various teams within the organization to communicate timelines, risk adjustment methodology, program expectations and results of risk adjustment initiatives. Collaborate to evaluate trends, audit results and risk indicators using data-driven insights. Develop dashboards and presentations for an executive audience.
- Plan, scope, and manage internal and external audits and ensure audits align with regulatory standards such as CMS HCC guidelines, OIG expectations and organizational audit policies.
- Responsible for documenting workflow process, standard operating policies and procedures and establishing robust monitoring programs that ensures performance metrics are achieved in compliance with CMS regulations, mitigating our risk adjustment data validation exposure/risk. Develop and track provider patterns in coding and create feedback loop to the Prospective Team for external provider education. Utilize analytics to identify which providers or conditions are high-risk.
Qualifications
Required
- Bachelor's Degree or equivalent, in field of study requiring consistent demonstration of communication, interpersonal, leadership and analytical skills, such as finance, accounting or business management or related field.
- 3 years of relevant experience in health care related field including experience in a leadership role with direct reports.
- 5 years of relevant experience In Risk Adjustment, Internal Audit, Compliance or Healthcare Risk Management in a health plan or medical group setting.
- 2 years of relevant previous experience with regulatory audits relating to Risk Adjustment; RADVs, OIG, IPMs etc.
- CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire required Or
- CRT-Professional Coder, Certified - Payer (CPC-P) - American Academy of Professional Coders American Academy of Professional Coders Upon Hire required
Preferred
- Master's Degree or equivalent
- 3 years of relevant experience in a clinical setting
- CRT-Certified Professional Medical Auditor (CPMA) - American Academy of Professional Coders American Academy of Professional Coders Upon Hire preferred
- LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire preferred Or
- LIC-Registered Nurse (RN) - State Other than Michigan State Other than Michigan Upon Hire preferred Or
- LIC-License Practical Nursing (LPN) - STATE_MI State of Michigan Upon Hire preferred Or
- LIC-License Practical Nursing (LPN) - State Other than Michigan State Other than Michigan Upon Hire preferred
Physical Demands
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here. On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status
Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name Risk Adjustment - PH Managed Benefits
Employment Type Full time
Shift Day (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8 a.m. to 5 p.m.
Days Worked Monday to Friday
Weekend Frequency N/A
CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
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Corewell Health
Feb 19, 2026