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Medicare Risk Adjustment Jobs (NOW HIRING)

Centrum Health

Risk Adjustment Analyst

Doral, FL · On-site

ACA, Medicare, ACO REACH, MSSP, and Medicaid. The Risk Adjustment and Quality Analyst will be responsible for working both independently and collaboratively between multiple departments such as ...

LSMA Management Inc

Medicare Provider Advocate

Fresno, CA · On-site

$36.05 - $38.46/hr

The Medicare Provider Advocate supports the implementation, execution, and optimization of Risk Adjustment strategies across the LaSalle provider network. This role collaborates with internal teams ...

LSMA Management Inc

Medicare Provider Advocate

Fresno, CA · On-site

$36.05 - $38.46/hr

The Medicare Provider Advocate supports the implementation, execution, and optimization of Risk Adjustment strategies across the LaSalle provider network. This role collaborates with internal teams ...

LSMA Management Inc

Medicare Provider Advocate

Fresno, CA · On-site

$36.05 - $38.46/hr

The Medicare Provider Advocate supports the implementation, execution, and optimization of Risk Adjustment strategies across the LaSalle provider network. This role collaborates with internal teams ...

Centrum Health

Risk Adjustment Analyst

Doral, FL · On-site

ACA, Medicare, ACO REACH, MSSP, and Medicaid. The Risk Adjustment and Quality Analyst will be responsible for working both independently and collaboratively between multiple departments such as ...

Honest Health

Sr. Risk Adjustment Auditor

$82K - $101K/yr

Direct experience with Medicare Advantage (Part C) risk adjustment models and HCC coding required * Experience auditing vendor-delivered work and/or CDI programs preferred * One or more of the ...

Molina Healthcare

VP, Risk Adjustment

Long Beach, CA · On-site

$137K - $184K/yr

Provides executive oversight of all risk adjustment programs across Medicare Advantage, Medicaid, and ACA Marketplace lines of business, ensuring alignment of operational activities with ...

Oscar Health

Auditor, Risk Adjustment

Atlanta, GA · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Oscar Health

Auditor, Risk Adjustment

Dallas, TX · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Oscar Health

Auditor, Risk Adjustment

Tempe, AZ · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

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Medicare Risk Adjustment information

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How much do medicare risk adjustment jobs pay per hour?

As of Jul 2, 2026, the average hourly pay for medicare risk adjustment in the United States is $22.42, according to ZipRecruiter salary data. Most workers in this role earn between $16.11 and $27.16 per hour, depending on experience, location, and employer.

What Are Jobs in Medicare Risk Adjustment?

Jobs in Medicare risk adjustment include work in data analytics, consulting, insurance, and closely related industries. Your duties and responsibilities differ depending on the type of work. For example, as a Medicare risk-adjustment consultant, you provide advice and recommendations to healthcare organizations or an insurance provider on how to mitigate risk across a customer pool. Data analytics and statistics specialists gather and analyze insurance and Medicare data and documentation from hospitals, healthcare providers, and other medical care facilities that accept Medicare. This includes reviewing different types of diagnosis and comparing patient chart information. Some health care providers have in-house risk adjustment workers, while others contract with outside consulting and analytics firms.

What is the difference between Medicare Risk Adjustment vs Medicare Coding Specialist?

AspectMedicare Risk AdjustmentMedicare Coding Specialist
Primary FocusAssessing patient health risk scores for reimbursementAccurately coding medical diagnoses and procedures
Required CredentialsCertifications in risk adjustment or coding, often CPC or RHITCertifications like CPC, CCS, or RHIT
Work EnvironmentHealth plans, risk adjustment companies, healthcare providersHospitals, clinics, billing departments
Industry UsageUsed for Medicare Advantage plan reimbursementsUsed for medical billing and claims processing

While both roles involve healthcare coding and require similar certifications, Medicare Risk Adjustment focuses on evaluating patient health data to determine reimbursement levels, whereas Medicare Coding Specialists concentrate on accurately coding diagnoses and procedures for billing purposes.

What is Medicare Risk Adjustment?

Medicare Risk Adjustment is a process used by the Centers for Medicare & Medicaid Services (CMS) to adjust payments to Medicare Advantage plans based on the health status and demographic characteristics of their enrolled beneficiaries. The goal is to ensure that plans receive appropriate compensation for taking care of members with varying levels of health risk. This system uses diagnosis codes and other data to predict future healthcare costs, encouraging plans to provide comprehensive care and accurately document patient conditions.

What are some common challenges faced by professionals working in Medicare Risk Adjustment roles?

Professionals in Medicare Risk Adjustment often encounter challenges such as staying current with frequently changing CMS regulations, ensuring the accurate capture and documentation of patient diagnoses, and collaborating effectively with providers to optimize risk scores. The role requires meticulous attention to detail when reviewing medical records and coding, as well as strong communication skills to educate and support healthcare teams. Additionally, there can be pressure to meet strict deadlines for data submission and to ensure compliance with audit standards.

What are the key skills and qualifications needed to thrive in Medicare Risk Adjustment, and why are they important?

To excel in Medicare Risk Adjustment, you need a solid understanding of medical coding (especially ICD-10), healthcare regulations, and risk adjustment methodologies, often supported by credentials like CRC or CPC certifications. Familiarity with data analytics platforms, EHR systems, and specialized risk adjustment software is typically required. Strong attention to detail, analytical thinking, and effective communication are crucial soft skills for interpreting complex clinical data and collaborating across teams. These competencies ensure accurate risk scores, compliance with CMS requirements, and optimal financial outcomes for healthcare organizations.
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Medicare Risk Adjustment jobs near you
Director, Risk Adjustment - Hybrid

Director, Risk Adjustment - Hybrid

EmblemHealth

New York, NY • On-site

$135K - $253K/yr

Full-time

This job post has expired today. Applications are no longer accepted.

Job description

Summary of Job
Develop and execute a comprehensive annual Risk Adjustment strategy that supports the Company strategies and improves the quality of care delivered to Emblem members, and to ensure the plan reimbursement accurately reflects the clinical diagnosis of our Medicare, Medicaid, and Affordable Care Act (ACA) members. Develop and execute an annual Provider Risk Adjustment strategy to improve the accuracy of their diagnosis coding through education and engagement of our risk adjustment programs, reimbursement models and the ongoing development/ enhancement of support capabilities that complement their clinical practice model. Prepare and present provider risk adjustment results at all Emblem joint operating committee meetings and monthly risk adjustment operational meetings. Select and manage best-in-class risk adjustment vendors to drive continual improvement in the accuracy of diagnosis coding for Medicare, Medicaid, and ACA members. Manage the ongoing performance, compliance and return on investment for each risk adjustment vendor. Create and maintain a capabilities framework that is member and provider centric and is appropriate given for the clinical and demographic dynamics of members in risk adjusted products. Manage the creation and timely production of risk adjustment operation and financial performance reports for all risk adjustment programs, and lead monthly risk adjustment operation meetings with Emblem leaders for VP, Risk Adjustment. Be a strategic partner with the Actuarial, Quality and Product teams to enhance risk adjustment interventions and results. Establish enterprise-wide monitoring and reconciliation reports to ensure that risk adjustment vendor results are accurately, timely and completely submitted to government entities.
Responsibilities
  • Develop, manage, and improve all retrospective risk adjustment programs to retrospectively identify, retrieve, code and submit diagnostic information from providers on EmblemHealth members enrolled in Medicare, Medicaid, and ACA products; manage all vendor relationships that support these retrospective activities.
  • Develop, manage, and improve prospective and concurrent risk adjustment programs to ensure accurate capture and reporting of diagnostic information for EmblemHealth members enrolled in Medicare, Medicaid and ACA products.
  • Work with risk adjustment vendors and providers to execute in office assessment programs through which they 1) identify members based on clinical needs and quality gaps, 2) outreach to patients to encourage them to make office visits to receive services and 3) completely and accurately document all diagnostic conditions.
  • Manage the In-Home Assessment risk adjustment vendor program.
  • Manage team completing revenue management opportunities for Medicaid, Medicare and Health Exchange products which includes identification of risk score opportunities, suspects, analysis and tracking of performance and attribution of interventions.
  • Direct EmblemHealth provider relationship and engagement risk adjustment activities.
  • Direct interaction with the CFO, CEO and other physician leaders of ACPNY groups and other large, sophisticated medical groups to integrate our programs into the provider's operations.
  • Analyze data to identify submission trends against historic data and membership changes and recommend opportunities to improve accuracy and completeness of all government submissions.
  • Collaborate with EmblemHealth medical management, quality, marketing & sales and network departments to identify opportunities to achieve efficiencies and improve effectiveness of risk adjustment activities by integrating both prospective and retrospective programs with care management, CMS Stars, Medicaid and Health Exchange quality programs, sales outreach and provider contracting.

Qualifications
  • Bachelor's Degree in Healthcare, Finance, Business, or related field (Required); Master's degree (Preferred)
  • 10 - 12+ years of relevant, professional work experience (Required)
  • Experience in healthcare, plan or provider operations and relations or related experience (Required)
  • Leadership experience - including staff and process management experience (Required)
  • Risk adjustment knowledge and expertise across Medicare, Medicaid, and Commercial exchange (Required)
  • Capacity to multi-task at high detail-oriented level (Required)
  • Strong communication skills (verbal, written, presentation, interpersonal) including executive leaders meeting experience (Required)
  • Strong working knowledge of MS Office - Word, Excel, PowerPoint, Access, Outlook (Required)
  • Strong analytical and logical skills paired with strong attention to detail (Required)

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