Quality Risk Adjustment Advisor IV (Health Plan experience required)

Job Summary:

The Quality Risk Adjustment Advisor IV is responsible for leading key components of the Quality Risk Adjustment (QRA) programs, including prospective programs, chart retrieval and coding processes, while ensuring compliance with regulatory standards and optimizing quality outcomes. This role partners closely with internal stakeholders and external vendors to enhance operational effectiveness and leverage artificial intelligence (AI) technologies to improve data accuracy, efficiency, and overall program performance. 

Essential Functions: Serve as a subject matter expert in Risk Adjustment operations, supporting prospective programs, chart retrieval and coding processes.

Identify and recommend strategies to optimize risk adjustment processes and improve quality metrics across insourced and outsourced activities, including leveraging AI for process enhancement.

Partner with vendors to support execution of operational production plans and contractual requirements.

Monitor vendor performance and identify opportunities to improve efficiency, quality, and cost management.

Collaborate with QRA Compliance to support development and maintenance of quality assurance protocols.

Conduct audits and assessments to ensure accuracy, completeness, and efficiency.

Research and evaluate technological solutions, including AI/NLP tools.

Partner with Data Science, IT, and Sourcing teams to support deployment of AI solutions.

Collaborate with cross-functional teams to support operational goals.

Identify and implement process improvements.

Monitor and analyze key performance indicators (KPIs).

Gather and translate business requirements into actionable recommendations.

Assess build vs. buy AI solutions.

Support evaluation and monitoring of AI solution performance.

Provide guidance and informal coaching to stakeholders as needed. Perform any other job related duties as requested.

Education and Experience: Bachelor's degree in Health Administration, Healthcare Management, or a related field required

Master's degree is preferred Equivalent years of relevant work experience may be accepted in lieu of required education Seven (7) years experience in risk adjustment, medical record review, coding, or quality management required

Two (2) years experience with AI solutions in a healthcare setting  required

Leadership experience preferred Competencies, Knowledge and Skills: Knowledge of ICD-10 Coding

Knowledge of HCC Risk Adjustment models

Knowledge of CMS regulatory guidelines

Strong analytical and problem-solving skills

Ability to apply AI technologies in healthcare

Strong communication and collaboration skills

Ability to influence stakeholders without direct authority Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required

Compensation Range: $83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture

Cultivate Partnerships

Develop Self and Others

Drive Execution

Influence Others

Pursue Personal Excellence

Understand the Business

  This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1    

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