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Risk Adjustment Manager manages an organization's risk adjustment processes to assess patient risk scores and ensure accurate reimbursement calculations. Utilizes patient health factors, their likely use of health care services, and the costs of those services to calculate payment adjustments, forecast revenue impacts, and identify coding gaps. Being a Risk Adjustment Manager implements processes and standards to ensure accurate, timely, and compliant reporting to government agencies for determining risk adjustment payments. Monitors risk adjustment performance and leads and executes strategies to optimize financial performance while maintaining regulatory compliance. Additionally, Risk Adjustment Manager requires a bachelor's degree. Typically reports to a director. The Risk Adjustment Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be a Risk Adjustment Manager typically requires 5 years experience in the related area as an individual contributor. 1-3 years supervisory experience may be required. Extensive knowledge of the function and department processes.
Risk Adjustment Director plans and directs an organization's risk adjustment processes to assess patient risk scores and ensure accurate reimbursement calculations. Researches and promotes modeling and analysis frameworks to evaluate patient health factors and risk probability and calculate payment adjustments and revenue impacts. Being a Risk Adjustment Director develops processes and standards to ensure accurate, timely, and compliant reporting to government agencies for determining risk adjustment payments. Collaborates with senior leaders to develop and integrate strategies that optimize financial performance while maintaining regulatory compliance. Additionally, Risk Adjustment Director requires a bachelor's degree. Typically reports to senior management. The Risk Adjustment Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. To be a Risk Adjustment Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function.
Risk Adjustment Analyst analyzes healthcare data to assess patient risk scores and ensure accurate reimbursement calculations. Utilizes patient health factors, their likely use of health care services, and the costs of those services to calculate payment adjustments, forecast revenue impacts, and identify coding gaps. Being a Risk Adjustment Analyst reviews medical claims, encounter data, and electronic health records to ensure proper coding of diagnoses and accurate reporting to government healthcare programs. Prepares reports on risk adjustment performance and recommends strategies to optimize financial performance while maintaining regulatory compliance. Additionally, Risk Adjustment Analyst requires a bachelor's degree. Typically reports to a manager. The Risk Adjustment Analyst occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Risk Adjustment Analyst typically requires 2-4 years of related experience.
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