Quality and Risk Adjustment Manager



Quality and Risk Adjustment Manager

Position Summary:

The Quality and Risk Adjustment Manager, PHSO, is the subject matter expert and lead in developing and facilitating the implementation of new and existing healthcare Quality and Risk Adjustment strategies for a PHSO client. This position advises the client on quality and risk adjustment initiatives and provides support for program planning, patient campaigns, outreach tactics, and educational programs; conducts data collection; and reports and monitors key performance measurement activities for both quality and risk adjustment.

Job Description:

Primary Responsibilities

  • Manage a comprehensive and coordinated Quality and Risk Adjustment strategy for our PHSO client by: developing data mining strategies; facilitating collection methodology and an effective quality and risk adjustment program; standardizing gap closure workflows and strategies; providing support for patient campaigns, and facilitating the development and implementation of Quality and Risk Adjustment programs for internal and external PHSO clients.
  • Develop and maintain effective internal and external relationships through effective and timely communication.
  • Synthesize and organize data, present information, and provide executive summary of material.
  • Take initiative and action to respond, resolve and follow up regarding quality and risk adjustment with internal and external customers in a timely manner with outstanding customer service.
  • Develop and maintain an expert level of knowledge of PHSO Quality metrics (such as MSSP, HEDIS, MA 5-Star, NQF) and MA, ACA, and Medicaid risk-based reimbursement methodologies.
  • Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
  • Oversee and improve the various quality and risk adjustment processes.
  • Assist client with development of a comprehensive Risk Adjustment and Quality strategy and work plan, including workflow, outcome measures and performance evaluation.
  • Facilitate the development of key quality and risk adjustment key performance indicators.
  • Present quality performance results and findings regularly, including the overall measure performance, improvement strategies and tactics.
  • Serve as a quality and risk adjustment subject matter expert for internal and external clients.
  • Support activities of the PCV (Preventative Care Visit), patient outreach, and physician educational campaigns.
  • Perform other duties as assigned.


  • Bachelor’s degree; BSN, LPN, RHIA preferred
  • 5+ years of experience in Quality Management and experience in HEDIS, MIPS/MSSP, and MA 5-Star, preferably in a health system or clinic setting
  • 3+ years demonstrated management and team development skills
  • 3+ years’ experience and proven success managing, implementing and auditing clinical quality programs
  • 3+ years’ experience within healthcare, health plan, or health system, including payer, hospitals, Medicare/Medicaid, provider environment, or managed care
  • Knowledge of Risk Adjustment Payment methodologies; understanding of CMS HCC, HHC, and Medicaid
  • Medicare Advantage knowledge strongly preferred
  • Proficiency with clinical data management and statistical quality tools
  • Analytical and quantitative problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Ability to operate in a fast-paced and dynamic environment
  • Excellent verbal, written, and interpersonal communication skills; ability to present in front of a group
  • Excellent organizational capabilities with ability to work effectively as a team player
  • Strong aptitude for critical thinking and demonstrated data skills
  • Capable of meeting deadlines and executing projects with minimal supervision
  • Willingness to acquire new knowledge from an unfamiliar domain
  • Ability to manage multiple job functions, priorities, and deadlines under pressure with shifting priorities in an expedient and decisive manner
  • Ability to collaborate and work with all professional levels, internally and externally
  • Detail oriented
  • Proficiency in Microsoft Office Programs including Word, PowerPoint, Excel, and Outlook

Working Conditions

  • While performing the duties of this job, the employee works in normal office working conditions.


  • The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.

Lumeris is an EEO/AA employer M/F/V/D.


Remote – MO

Time Type:

Full time


From <https://lumeris.wd1.myworkdayjobs.com/en-US/LC/job/Remote—MO/Quality-and-Risk-Adjustment-Manager_R0004035?mode=job&iis=Indeed.com&iisn=Indeed.com>