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Nurse Risk Adjustment Jobs (NOW HIRING)

Mass Advantage

Manager, Risk Adjustment

Worcester, MA · On-site

Registered Nurse (RN) desired. * CRC (Certified Risk Adjustment Coder), CPC, or CCS certification preferred. * 7+ years in Medicare Advantage risk adjustment, with at least 3 years in a plan-side ...

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$65

How much do nurse risk adjustment jobs pay per hour?

As of Aug 19, 2026, the average hourly pay for nurse risk adjustment in the United States is $38.62, according to ZipRecruiter salary data. Most workers in this role earn between $29.57 and $43.27 per hour, depending on experience, location, and employer.

What is a nurse risk adjustment?

Nurse risk adjustment nurses are specialized healthcare professionals who review patient medical records to ensure accurate documentation of diagnoses and health conditions. Their work supports the risk adjustment process, which helps health plans and providers receive appropriate compensation based on the health status of their patient populations. These nurses use their clinical expertise to identify missing or undocumented conditions, collaborate with providers to improve documentation accuracy, and help ensure compliance with federal guidelines. By doing so, they play a key role in improving patient care quality and the financial health of healthcare organizations.

What are the key skills and qualifications needed to thrive as a nurse risk adjustment?

To thrive as a Nurse Risk Adjustment, you need a solid background in clinical nursing, comprehensive knowledge of medical coding (especially ICD-10), and familiarity with risk adjustment methodologies, typically supported by RN licensure and experience in case management or chart review. Proficiency with electronic health record (EHR) systems, coding software, and sometimes a Certified Risk Adjustment Coder (CRC) credential is valuable. Attention to detail, analytical thinking, and strong communication skills help nurses accurately review documentation and collaborate with providers. These skills ensure accurate coding and risk stratification, which directly impact healthcare reimbursement and quality reporting.

How does a nurse risk adjustment professional typically collaborate with coding and provider teams to ensure accurate risk scoring?

Nurse Risk Adjustment professionals often work closely with medical coders and healthcare providers to review patient documentation and ensure diagnoses are captured accurately for risk adjustment purposes. They may participate in interdisciplinary meetings, provide education to providers on documentation best practices, and clarify coding queries. This collaborative approach helps optimize the accuracy of risk scores, which impacts reimbursement and quality metrics. Effective communication and teamwork are essential in this role to support compliance and achieve organizational goals.

What is the difference between Nurse Risk Adjustment vs Nurse Case Manager?

AspectNurse Risk AdjustmentNurse Case Manager
CertificationsRN license, risk adjustment trainingRN license, case management certification
Work EnvironmentInsurance companies, healthcare analyticsHospitals, clinics, patient homes
Employer & IndustryHealth plans, insurance providersHealthcare providers, hospitals

While both roles require RN licensure, Nurse Risk Adjustment focuses on analyzing and coding patient data for insurance risk models, whereas Nurse Case Managers coordinate patient care and manage treatment plans. Understanding these differences helps professionals choose the right career path within healthcare and insurance industries.

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Nurse Risk Adjustment jobs near you
Infographic showing various Nurse Risk Adjustment job openings in the United States as of August 2026, with employment types broken down into 70% Full Time, 15% Part Time, 5% Temporary, and 10% Contract. Highlights an 85% In-person, and 15% Remote job distribution, with an average salary of $80,321 per year, or $38.6 per hour.

Manager, Risk Adjustment

Mass Advantage

Worcester, MA • On-site

Full-time

Re-posted 5 days ago

Job description

Description

Mass Advantage is a Medicare Advantage health plan, located in the heart of Worcester County, headquartered in Worcester MA. Mass Advantage is owned and designed by UMass Memorial Health providers with their patients' needs in mind.


We are looking for a Manager of Risk Managment to oversee Mass Advantages's full suite of Risk Adjustment activities. This position is responsible for the strategy, execution and performance of Medicare risk adjustment programs, infrastructure and systems to meet business objectives, revenue expectations, management of external vendors, interaction with Providers, regulatory audits, and compliance with CMS regulations. The Manager of Risk Management is also responsible for analysis, projections, and assessment of Medicare revenue initiatives for senior products; leading and coordinating enterprise risk adjustment initiatives, working with the necessary areas of Mass Advantage and UMass Memorial Health Operations as well as vendor partners.


Essential Duties and Responsibilities:

Program Strategy & Execution

  • Own end-to-end RA strategy across prospective (point-of-care capture, suspecting, provider workflows) and retrospective (chart review, coding validation) programs, ensuring complete, accurate, and compliant HCC documentation under the applicable CMS-HCC model (including V24 -V28 transition management).
  • Evaluate current vendor performance, renegotiating or sunsetting SOWs where internal capability is superior.
  • Serve as the plan-side counterpart to UMMH CDI, HIM, and Coding leadership, coordinating with the CMO's office to embed documentation workflows into Epic-based clinical practice rather than layered on top of it.
  • Partner with Network and Clinical Services to design provider-facing education, scorecards, and incentive structures that drive documentation accuracy without creating coding-driven behavior.
  • Develop provider-level performance reporting that is transparent, defensible, and actionable.

RADV, Audit & Compliance

  • Lead RADV audit readiness and response, including medical record retrieval, validation, submission strategy, and cross-functional coordination with Legal, Compliance, and Finance to mitigate financial and compliance risk.
  • Maintain a comprehensive QA program covering RADV, OIG, and internal audits - monitoring the work of internal coders, contracted vendors, and provider documentation alike.
  • Own encounter data integrity, including EDPS submission accuracy, RAPS/EDPS reconciliation, and error resolution.

Analytics, Finance & Bid Support

  • Build and maintain the RA analytics layer - dashboards, KPIs, and provider/member-level reporting that drive continuous improvement in risk score accuracy, coding yield, and program ROI.
  • Partner with Actuarial and Finance on bid development, producing defensible risk score projections, trend analysis, and revenue assumptions grounded in population severity and program performance.
  • Communicate results to executive and board audiences through clear reports, dashboards, and presentations.

Program & Team Leadership

  • Set departmental goals, budgets, and tactical plans aligned with enterprise strategy and financial targets.
  • Other duties may be assigned as needed. 

* Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.


Requirements

  • Bachelor's degree in a relevant field; Master's (MBA, MHA, MPH) preferred.
  • Registered Nurse (RN) desired. 
  • CRC (Certified Risk Adjustment Coder), CPC, or CCS certification preferred.
  • 7+ years in Medicare Advantage risk adjustment, with at least 3 years in a plan-side role (not solely provider-side or vendor-side).
  • Direct, hands-on RADV experience - working fluency with the CMS-HCC model, including the  V24-V28  transition and its financial implications.
  • Demonstrated experience managing or transitioning RA vendors (coding, chart retrieval, in-home assessment).
  • Strong analytical skills: able to interrogate data directly in SQL, Power BI, or Tableau, or to spec analytics requirements with precision.+
  • Strong Microsoft Office skills (Word, Outlook, Excel and PP).


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