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$40

How much do medicare risk adjustment jobs pay per hour?

As of Jun 11, 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.
More about Medicare Risk Adjustment jobs
What cities are hiring for Medicare Risk Adjustment jobs? Cities with the most Medicare Risk Adjustment job openings:
What are the most commonly searched types of Medicare Risk Adjustment jobs? The most popular types of Medicare Risk Adjustment jobs are:
What states have the most Medicare Risk Adjustment jobs? States with the most job openings for Medicare Risk Adjustment jobs include:
What job categories do people searching Medicare Risk Adjustment jobs look for? The top searched job categories for Medicare Risk Adjustment jobs are:
Medicare Risk Adjustment jobs near you
Infographic showing various Medicare Risk Adjustment job openings in the United States as of June 2026, with employment types broken down into 1% Locum Tenens, 6% As Needed, 45% Full Time, 44% Part Time, and 4% Contract. Highlights an 93% Physical, 1% Hybrid, and 6% Remote job distribution, with an average salary of $46,633 per year, or $22.4 per hour.

Risk Adjustment Program Manager

MetroPlusHealth

Manhattan, NY • On-site

$125K - $145K/yr

Full-time

Posted 17 days ago

MetroPlusHealth rating

7.8

Company rating: 7.8 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

166th of 260 rated insurance

Job description

We are looking for a professional with experience in Risk Adjustment for the Medicare, Medicaid and Qualified Health Plan ("Exchange") populations. As a Risk Adjustment Program Manager, you will develop strategies to ensure risk adjustment data accuracy, coordinate the work of internal and external partners, and respond to new requirements from CMS or company leadership. You will supervise the work of analysts and specialists to reconcile encounter submissions, prepare ongoing reporting and analyze the success of past projects.
This role is ideal for candidate with experience in Risk Adjustment ready to take the next step in their career at a leading not-for-profit health insurer focused on improving the health of all New Yorkers.
Scope of Role & Responsibilities
  • Ensure high-quality encounter submissions: Use CMS response files, vendor reports, and internal claims data to determine the source of submission or adjudication errors. Work with key stakeholders to resolve issues and resubmit files.
  • Identify and close risk score gaps: Continually monitor member- and provider-facing activities to identify data inaccuracies or care gaps. Work with vendors and provider partners to resolve issues and improve outcomes.
  • Use data to refine Risk Adjustment strategy: Assess our Risk Adjustment program by reviewing year-over-year risk condition persistence and the impact of supplemental activities. Modify and refine Risk Adjustment strategy based on your findings.
  • Serve as Subject Matter Expert: Work collaboratively with other departments to ensure Risk Adjustment goals are integrated into MetroPlusHealth operations. Educate departments across the organization about how their activities impact risk adjustment.
  • Prepare ongoing reporting: Supervise analysts and utilize our Data Warehouse to conduct in-depth analysis of critical issues, including claims, enrollment and provider coding trends.
  • Work proactively with vendors: Monitor and guide external vendor partners to ensure program goals are being met.
  • Ensure regulatory compliance: Continually review CMS or state guidance and regulations around Risk Adjustment, encounter submission and related topics. Update internal processes to ensure strict adherence to regulatory guidelines.
  • Lead Request for Proposal (RFP) process and manage new vendor implementations.
  • Supervise and provide feedback to analysts and specialists.

Required Education, Training & Professional Experience
  • Bachelor's degree required, Master's preferred.
  • At least 6 years' experience working in health care, including at least 3 years working in Risk Adjustment at a Health Insurer, Provider Group or Risk Adjustment vendor.
  • Supervisory experience in analytics or healthcare setting.
  • Thorough understanding of Medicare, Medicaid and commercial insurance markets and Risk Adjustment models, including at least two of the following models: HHS-HCC (Qualified Health Plans), 3M CRG (New York State Medicaid), CMS-HCC (Medicare).
  • Experience modeling member-level risk score impacts of various activities.
  • Strong analytical skills, including using SQL or other programming language to query large relational databases.
  • Proactive communication style and ability to work with a variety of stakeholders to achieve project goals.

Professional Competencies
  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication

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