Manager, Risk Adjustment Operations at Capital Blue Cross

United States

$83.8k - $157.89k

<h2>Position Description</h2> <p><em>Base pay is influenced by several factors including a candidate’s qualifications, relevant&nbsp;experience, and&nbsp;anticipated&nbsp;contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be&nbsp;modified&nbsp;in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental &amp; Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.&nbsp;&nbsp;&nbsp;</em></p> <p>At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and&nbsp;it’s&nbsp;why our employees consistently vote us one of the “Best Places to Work in PA.”&nbsp;&nbsp;</p> <p>The Manager, Risk Adjustment Operations provides end-to-end operational management, delivery and support to new and existing MA and ACA Risk Adjustment Programs. Working closely with the Director, Risk Adjustment Programs, this position drives execution of operational priorities, manages program performance, and ensures timely delivery of strategic initiatives through data-driven decision making, cross-functional coordination, and operational accountability. The manager will be responsible for professional coaching and mentoring of program team members while fostering continuous process improvement.</p> <h2>Responsibilities and Qualifications</h2> <ul> <li>Drive day-to-day operational execution of Medicare Advantage and ACA Risk Adjustment initiatives, ensuring project milestones, regulatory deadlines, and operational deliverables are completed on schedule.</li> <li>Develop and maintain integrated project plans, operational calendars, risk logs, and status reporting to support successful program execution.</li> <li>Monitor program performance through dashboards, KPIs, and operational metrics; identify trends, escalate risks, and recommend data-driven improvements.</li> <li>Coordinate cross-functional activities across Analytics, Coding, Provider Engagement, Chart Retrieval, Actuarial, Compliance and vendor partners to ensure successful execution of operational priorities.</li> <li>Hold internal teams and external vendors accountable for operational performance, deliverables, timelines, service level expectations, and issue resolution.</li> <li>Proactively identify operational barriers and develop mitigation plans to minimize impact to program performance.</li> <li>Strategic vision to align business operations with broader organizational goals.</li> <li>Business acumen to drive growth and success through data-driven decisions.</li> <li>Lead operational vendor onboarding and offboarding activities, support vendor evaluations and RFP processes, and partner with procurement and other stakeholders to ensure successful implementation and ongoing operational performance.</li> </ul> <p><strong><u>Skills:</u></strong></p> <ul> <li>Strong verbal and written communication skills, including the ability to communicate complex operational issues clearly to business partners and leadership.</li> <li>Strong organizational and project management skills, with demonstrated ability to manage multiple priorities, deadlines, dependencies, and deliverables.</li> <li>Ability to lead cross-functional initiatives and build effective working relationships across internal departments and external vendor partners.</li> <li>Strong analytical and problem-solving skills, including demonstrated ability to interpret dashboards, key performance indicators, and operational reporting to monitor performance, identify risks, and drive operational decision-making.</li> <li>Strong business acumen, including the ability to understand operational, financial, contractual, and regulatory considerations.</li> <li>Ability to proactively identify risks, remove barriers, develop mitigation plans, and escalate issues appropriately.</li> <li>Strong vendor management skills, including experience in supporting vendor evaluation, onboarding, implementation, performance monitoring, and transitions.</li> <li>Ability to work independently, exercise sound judgement, and drive accountability in a fast-paced, deadline-oriented environment.</li> <li>Proficiency with Microsoft Office applications, including advanced Excel skills; ability to interpret and leverage Power BI or other business intelligence reporting preferred.</li> </ul> <p><strong><u>Knowledge:</u></strong></p> <ul> <li>Working knowledge of Medicare Advantage and ACA Risk Adjustment regulations and payment methodologies.</li> <li>Working knowledge of industry standards and best practices for Risk Adjustment operations.</li> <li>Working knowledge of cross-functional Risk Adjustment operational processes, including provider engagement, analytics, coding, vendor management, and regulatory compliance.</li> </ul> <p><strong><u>Experience:</u></strong></p> <ul> <li>5 years of Operations and/or Program management.</li> <li>3 years of Risk Adjustment Operations or Program Management.</li> <li>Experience leading complex, cross-functional operational initiatives involving multiple stakeholders and competing priorities.</li> <li>Experience supporting vendor selection, RFP processes, business requirements, Statement of Work (SOWs), implementation, onboarding, and ongoing vendor performance management.</li> <li>Experience monitoring operational performance and driving execution to meet regulatory deadlines and business objectives.</li> <li>1 year staff, team lead or project lead experience.</li> <li>Experience supervising staff and provider operational leadership across cross-functional programs or initiatives preferred.</li> </ul> <p><strong><u>Education and Certifications:</u></strong></p> <ul> <li>Bachelor’s degree in business administration, Healthcare Administration, Public Health, Health Information Management, Finance, Economics or 9 years relevant and progressive experience in lieu of bachelor's degree.</li> <li>Lean Six Sigma or other operational excellence/process improvement certification preferred.</li> </ul> <p><strong><u>Physical Demands:</u></strong></p> <ul> <li>While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.</li> <li>The employee must be able to work over 40 hours per week.</li> <li>The employee must occasionally lift and/or move up to 5 pounds.</li> </ul> <h2>About Us</h2>We recognize that work is a part of life, not separate from it, and&nbsp;foster&nbsp;a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.&nbsp;&nbsp;We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best,&nbsp;you’ll&nbsp;help us live our mission of improving the health and well-being of our members and the communities in which they live.&nbsp;&nbsp;