Note: The job is a remote job and is open to candidates in USA. Capital Blue Cross is a health insurance organization focused on improving the health and well-being of its members and communities. The Manager, Risk Adjustment Operations provides end-to-end operational management for Medicare Advantage and ACA Risk Adjustment Programs, overseeing execution, performance, regulatory deadlines, cross-functional coordination, vendors, and process improvement.
Responsibilities
- Drive day-to-day operational execution of Medicare Advantage and ACA Risk Adjustment initiatives, ensuring project milestones, regulatory deadlines, and operational deliverables are completed on schedule
- Develop and maintain integrated project plans, operational calendars, risk logs, and status reporting to support successful program execution
- Monitor program performance through dashboards, KPIs, and operational metrics; identify trends, escalate risks, and recommend data-driven improvements
- Coordinate cross-functional activities across Analytics, Coding, Provider Engagement, Chart Retrieval, Actuarial, Compliance and vendor partners to ensure successful execution of operational priorities
- Hold internal teams and external vendors accountable for operational performance, deliverables, timelines, service level expectations, and issue resolution
- Proactively identify operational barriers and develop mitigation plans to minimize impact to program performance
- Strategic vision to align business operations with broader organizational goals
- Business acumen to drive growth and success through data-driven decisions
- Lead operational vendor onboarding and offboarding activities, support vendor evaluations and RFP processes, and partner with procurement and other stakeholders to ensure successful implementation and ongoing operational performance
Skills
- Strong verbal and written communication skills, including the ability to communicate complex operational issues clearly to business partners and leadership
- Strong organizational and project management skills, with demonstrated ability to manage multiple priorities, deadlines, dependencies, and deliverables
- Ability to lead cross-functional initiatives and build effective working relationships across internal departments and external vendor partners
- Strong analytical and problem-solving skills, including demonstrated ability to interpret dashboards, key performance indicators, and operational reporting to monitor performance, identify risks, and drive operational decision-making
- Strong business acumen, including the ability to understand operational, financial, contractual, and regulatory considerations
- Ability to proactively identify risks, remove barriers, develop mitigation plans, and escalate issues appropriately
- Strong vendor management skills, including experience in supporting vendor evaluation, onboarding, implementation, performance monitoring, and transitions
- Ability to work independently, exercise sound judgement, and drive accountability in a fast-paced, deadline-oriented environment
- Proficiency with Microsoft Office applications, including advanced Excel skills; ability to interpret and leverage Power BI or other business intelligence reporting preferred
- Working knowledge of Medicare Advantage and ACA Risk Adjustment regulations and payment methodologies
- Working knowledge of industry standards and best practices for Risk Adjustment operations
- Working knowledge of cross-functional Risk Adjustment operational processes, including provider engagement, analytics, coding, vendor management, and regulatory compliance
- 5 years of Operations and/or Program management
- 3 years of Risk Adjustment Operations or Program Management
- Experience leading complex, cross-functional operational initiatives involving multiple stakeholders and competing priorities
- Experience supporting vendor selection, RFP processes, business requirements, Statement of Work (SOWs), implementation, onboarding, and ongoing vendor performance management
- Experience monitoring operational performance and driving execution to meet regulatory deadlines and business objectives
- 1 year staff, team lead or project lead experience
- Bachelor's degree in business administration, Healthcare Administration, Public Health, Health Information Management, Finance, Economics or 9 years relevant and progressive experience in lieu of bachelor's degree
- While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see
- The employee must be able to work over 40 hours per week
- The employee must occasionally lift and/or move up to 5 pounds
- Experience supervising staff and provider operational leadership across cross-functional programs or initiatives preferred
- Lean Six Sigma or other operational excellence/process improvement certification preferred
Benefits
- Medical, Dental & Vision coverage
- A Retirement Plan
- Paid Time Off
- Holidays
- Volunteer time off
- An Incentive Plan
- Tuition Reimbursement
- Flexible environment
- Training and continuing education
Company Overview
Company H1B Sponsorship