Upper Peninsula Health Plan

The Risk Adjustment Program Manager is responsible for leading, implementing, and optimizing UPHP’s managed care risk adjustment program. This role ensures accurate and compliance risk score capture to support appropriate revenue and quality performance in all lines of business. The manager oversees staff, vendor relationships, data analytics, coding accuracy, and cross-functional collaboration to develop and implement comprehensive strategies to manage and drive risk adjustment performance and compliance.

 

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Develops and executes a comprehensive Medicare and Medicaid risk adjustment strategy that aligns with regulatory and business goals; creates work plans and timelines for risk adjustment initiatives to achieve UPHP’s program goals. 

 

3. Supervises and manages the day-to-day responsibilities of risk adjustment department team members; responsible for scheduling of time off, coordinating new employee orientation, and conducting 90-day and annual performance appraisals in compliance with UPHP employee policies. 

 

4. Ensures compliance with CMS and state risk adjustment regulations, including appropriate use of HCCs, data submission standards, and audit readiness.

 

5. Leads risk adjustment workgroups and deliverables. Coordinates cross-functional collaboration with Clinical and Compliance departments to integrate risk adjustment efforts with broader population health strategies. 

 

6. Tracks overall portfolio of risk adjustment projects/initiatives. In collaboration with the accounting department, develops and measures return on investment (ROI) on risk adjustment initiatives, including coding interventions, vendor engagements, and member and provider outreach strategies.  

 

7. Oversees the analysis of risk scores, claims, encounters and supplemental data to identify opportunities for improved coding and accuracy.  Supports root cause analyses and develops targeted interventions designed to improve risk adjustment scores and initiative outcomes.

 

8. Develops and oversee delivery of risk adjustment training program to educate the provider network of best practices for coding and risk adjustment activities.

 

9. Manages relationships with external risk adjustment vendors, including monitoring and evaluating vendor performance. 

 

10. Develops and recommends annual operating budget and controls expenditures within approved budget objectives.

 

11. Maintains confidentiality of client data.

 

12. Performs other related duties as assigned or requested.

 

Bachelor’s degree in a health care administration, business, or related field; five (5) years of 

relevant experience in lieu of a degree will be considered. 

 

Master’s degree in health care administration, business, or related field; healthcare coding 

certification through AAPC or AHIMA

 

Three (3) years in health care risk adjustment, clinical quality operations, claims coding, 

compliance, or other relevant healthcare operations experience; one (1) year supervisory or 

project management experience required.

 

Three (3) years of experience in risk adjustment operations in a Medicare or Medicaid managed 

care organization or health plan; three (3) years supervisory experience.

 

Proficiency in Microsoft Office

Excellent problem solving, negotiation, and conflict resolution skills

Excellent human relation and oral/written communication

Excellent organizational and prioritization abilities

 

Proficiency in Medicare risk adjustment

Knowledge of MS PowerPoint 

Knowledge of state Medicaid guidelines and CMS regulations

Knowledge of Medicaid reimbursement models, managed care contracts and regulatory requirements 

Understanding of quality improvement programs

 

[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:

 

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Occasionally lifts supplies/equipment

Prolonged periods of sitting

Manual dexterity 

Works in office conditions, but occasional travel may be required

Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration

Subject to many interruptions

Occasionally subjected to irregular hours