WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
Lead Director, Medicare Advantage and Group ACA Risk Adjustment Informatics
Oregon, WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
Lead Director, Medicare Advantage and Group ACA Risk Adjustment Informatics
Oregon, WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Position Summary Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
Lead Director, Risk Adjustment Performance Reporting and Insights
Oregon, WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
Lead Director, Risk Adjustment Performance Reporting and Insights
Oregon, WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $232/hr
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
WI · On-site
$100 - $231.54/hr
Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state‑specific ... Ensure readiness for state audits and external reviews through robust data validation and ...
WI · On-site
$100 - $231.54/hr
Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state‑specific ... Ensure readiness for state audits and external reviews through robust data validation and ...
WI · On-site
$100 - $231.54/hr
Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state‑specific ... Ensure readiness for state audits and external reviews through robust data validation and ...
WI · On-site
$100 - $231.54/hr
Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state‑specific ... Ensure readiness for state audits and external reviews through robust data validation and ...
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
New
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements. * Experience at a health plan or ...
New
Lead Director, Healthcare Medicaid Risk Adjustment Analytics
Oregon, WI · On-site
$100 - $232/hr
This leader oversees the end‑to‑end risk adjustment lifecycle, including data management ... Ensure readiness for state audits and external reviews through robust data validation and ...
Lead Director, Healthcare Medicaid Risk Adjustment Analytics
Oregon, WI · On-site
$100 - $232/hr
This leader oversees the end‑to‑end risk adjustment lifecycle, including data management ... Ensure readiness for state audits and external reviews through robust data validation and ...
WI · On-site
$100 - $232/hr
This leader oversees the end‑to‑end risk adjustment lifecycle, including data management ... Ensure readiness for state audits and external reviews through robust data validation and ...
WI · On-site
$100 - $232/hr
This leader oversees the end‑to‑end risk adjustment lifecycle, including data management ... Ensure readiness for state audits and external reviews through robust data validation and ...
... relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement ... Assists in audits as it related to risk adjustment revenue management to address clinical issues ...
... relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement ... Assists in audits as it related to risk adjustment revenue management to address clinical issues ...
... relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement ... Assists in audits as it related to risk adjustment revenue management to address clinical issues ...
... relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement ... Assists in audits as it related to risk adjustment revenue management to address clinical issues ...
... audit readiness directly drive financial and compliance outcomes. You will sell to the leaders who ... Experience with the risk adjustment and reimbursement landscape (Medicare Advantage, ACA, Medicaid ...
... audit readiness directly drive financial and compliance outcomes. You will sell to the leaders who ... Experience with the risk adjustment and reimbursement landscape (Medicare Advantage, ACA, Medicaid ...
... audit readiness directly drive financial and compliance outcomes. You will sell to the leaders who ... Experience with the risk adjustment and reimbursement landscape (Medicare Advantage, ACA, Medicaid ...
... audit readiness directly drive financial and compliance outcomes. You will sell to the leaders who ... Experience with the risk adjustment and reimbursement landscape (Medicare Advantage, ACA, Medicaid ...
Hierarchical Condition Category (HCC) Coding Specialist
Madison, WI · On-site
$41.85/hr
... Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits. Works closely with physicians, team members, Quality, Compliance, partners at Enterprise and ...
Hierarchical Condition Category (HCC) Coding Specialist
Madison, WI · On-site
$41.85/hr
... Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits. Works closely with physicians, team members, Quality, Compliance, partners at Enterprise and ...
Telehealth Nurse Practitioner
Madison, WI · On-site +1
$600 - $720/day
Familiar with HEDIS and risk adjustment workflows * Medicare and Medicaid provider enrollment required * Comfortable delivering care through telehealth platforms * Ability to consistently work ...
Telehealth Nurse Practitioner
Madison, WI · On-site +1
$600 - $720/day
Familiar with HEDIS and risk adjustment workflows * Medicare and Medicaid provider enrollment required * Comfortable delivering care through telehealth platforms * Ability to consistently work ...
Medicare Risk Adjustment Audit information
What is a Medicare Risk Adjustment Audit?
A Medicare Risk Adjustment Audit is a review process conducted to ensure that healthcare providers are accurately reporting patient diagnoses to Medicare Advantage plans. This audit verifies that submitted diagnoses are supported by proper medical documentation, which affects how much Medicare pays to health plans. The goal is to prevent overpayments or underpayments and to ensure compliance with federal regulations. These audits are typically performed by the Centers for Medicare & Medicaid Services (CMS) or their contractors.
What are some common challenges faced by professionals in Medicare Risk Adjustment Audit roles, and how can they be addressed?
Professionals in Medicare Risk Adjustment Audit roles often encounter challenges such as interpreting complex medical documentation, staying updated on evolving CMS guidelines, and ensuring data accuracy for compliant risk scoring. Effective collaboration with coders, providers, and compliance teams is essential to resolve discrepancies and achieve audit objectives. Staying proactive in ongoing training and leveraging audit technologies can help address these challenges and contribute to high-quality, compliant results.
What are the key skills and qualifications needed to thrive as a Medicare Risk Adjustment Auditor, and why are they important?
To thrive as a Medicare Risk Adjustment Auditor, you need expertise in medical coding, healthcare compliance, and an understanding of CMS risk adjustment guidelines, often supported by a coding certification such as CPC or CRC. Familiarity with auditing software, electronic health records (EHRs), and data analytics tools is typically required. Attention to detail, analytical thinking, and strong communication are essential soft skills for reviewing documentation and conveying findings. These skills are crucial for ensuring accurate risk adjustment coding, regulatory compliance, and optimized reimbursement for healthcare organizations.
What is the difference between Medicare Risk Adjustment Audit vs Medicare Coding Specialist?
| Aspect | Medicare Risk Adjustment Audit | Medicare Coding Specialist |
|---|---|---|
| Primary Focus | Reviewing and verifying accuracy of risk adjustment data | Assigning correct medical codes for billing and documentation |
| Certifications | Risk adjustment or auditing certifications often preferred | Medical coding certifications like CPC or CCS |
| Work Environment | Healthcare organizations, insurance companies, auditing firms | Hospitals, clinics, billing companies |
| Industry Usage | Used in Medicare Advantage plan compliance and reimbursement | Used in medical billing and claims processing |
While both roles involve healthcare data, Medicare Risk Adjustment Auditors focus on verifying the accuracy of risk scores for Medicare payments, whereas Medicare Coding Specialists assign medical codes for billing purposes. Understanding these differences helps in choosing the right career path or job focus within the healthcare industry.
What are popular job titles related to Medicare Risk Adjustment Audit jobs in Wisconsin?
For Medicare Risk Adjustment Audit jobs in Wisconsin, the most frequently searched job titles are:
What job categories do people searching Medicare Risk Adjustment Audit jobs in Wisconsin look for?
The top searched job categories for Medicare Risk Adjustment Audit jobs in Wisconsin are:
What cities in Wisconsin are hiring for Medicare Risk Adjustment Audit jobs?
Cities in Wisconsin with the most Medicare Risk Adjustment Audit job openings:
Lead Director, Medicare Advantage and Group ACA Risk Adjustment Informatics
WI • On-site
$100 - $232/hr
Other
Medical, Dental, Vision, Retirement, PTO
Posted 8 days ago
Job description
We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.
Position SummaryRevenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and financial valuations. This role is responsible for driving risk score accuracy and completeness, ensuring regulatory compliance, and delivering actionable data-informed opportunities. The role is highly visible within the enterprise and will be a key contributor to strategic decision-making with senior management.
This role may sit anywhere in the US.
Key ResponsibilitiesRisk Adjustment & Business Performance- Lead enterprise risk adjustment analytics supporting risk score completeness, accuracy, engagement, recapture, and algorithms.
- Leverage claims and clinical data for deep learning into drivers of performance and model impacts.
- Proactively engage with stakeholders on emerging trends, rising risk, and data-driven opportunities
- Oversee the analytics that drive risk adjustment intervention activities, including prospective and retrospective programs.
- Directs the prioritization and performance evaluation of outreach, engagement, and clinical documentation initiatives.
- Lead the development and implementation of advanced predictive analytics and AI solutions to support risk adjustment, population health, and business performance initiatives.
- Drive innovation through automation, advanced analytics, and emerging technologies that improve efficiency and scalability
- Measure and evaluate intervention effectiveness and overall business impact
- Translate complex analytical findings into practical recommendations that improve operational, clinical, and financial outcomes.
- Partner with technology and data engineering teams to enhance data architecture, automation, and analytics capabilities.
- Partner with executive leadership, market leaders, finance, actuarial, service operations, and clinical teams to support strategic planning and performance improvement efforts.
- Provide executive-level presentations and recommendations that influence organizational strategy and investment decisions.
- Manage data relationships with external vendors and business partners
- Ensure adherence to CMS regulations, data governance policies, and organizational compliance expectations.
- Lead analytical support for compliance reviews and risk adjustment governance activities
- Establish and maintain controls that promote data integrity, auditability, transparency, and accuracy.
- Monitor regulatory and industry changes, assess business impact, and ensure timely implementation of required analytic and reporting enhancements.
- Lead, mentor, and develop a high-performing team of leaders and individual contributors across analytics, informatics, data science, and related disciplines.
- Foster a culture of collaboration, innovation, continuous improvement, and results-oriented execution.
- Champion technical excellence and continuous learning in areas including risk adjustment analytics, AI modeling, SQL, SAS, Python, BigQuery, and similar
- 10+ years of experience in healthcare analytics, informatics, risk adjustment, actuarial, finance, data science, or related disciplines.
- 2+ years of leadership experience (direct reports, team lead).
- Advanced technical proficiency in SQL, SAS, Python, BigQuery, or similar
- Experience with predictive analytics, machine learning, financial modeling, or data science concepts
- Demonstrated ability to influence leadership and deliver measurable business results.
- Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements.
- Experience at a health plan or provider system
- Bachelor's degree or equivalent professional work experience
- Master's degree in Business, Informatics, Analytics, Finance, Statistics, Computer Science, Public Health, Healthcare analytics, Actuarial, Mathematics, Economics, or equivalent combination of advanced education, professional certification, or demonstrated subject matter expertise preferred
The typical pay range for this role is:
$100,000.00 - $231,540.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 09/06/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.