Clinical Risk Adjustment Manager

Job description

Overview The Clinical Risk Adjustment Manager serves as Cotiviti's internal subject matter expert on Medicare Advantage risk adjustment methodology, NCQA/HEDIS quality measures, and regulatory compliance. This individual ensures our risk adjustment and quality products remain compliant, effective, and responsive to evolving CMS regulations, industry standards, and market demands. The role combines deep clinical knowledge with strategic market intelligence to inform product development and support commercial success. Responsibilities: Key Responsibilities: - Monitor and interpret CMS, state Medicaid, and industry risk adjustment and quality regulations. - Provide SME guidance to Product, Sales, and Account Management on RA policy and program implications. - Partner with product teams to ensure solutions align with regulatory and audit requirements. - Engage with industry groups (e.g., RISE, AHIP) to stay ahead of emerging trends. - Translate regulatory changes into actionable product and roadmap recommendations. Risk Adjustment Expertise: - Serve as the primary internal authority on CMS-HCC risk adjustment models, coding guidelines, and regulatory requirements. - Monitor and interpr...