The Clinical Risk Adjustment Manager serves as Cotiviti's internal subject matter expert on Medicare Advantage risk adjustment methodology, NCQA/HEDIS quality measures, and regulatory compliance. This individual ensures our risk adjustment and quality products remain compliant, effective, and responsive to evolving CMS regulations, industry standards, and market demands. The role combines deep clinical knowledge with strategic market intelligence to inform product development and support commercial success.

Key Responsibilities

• Monitor and interpret CMS, state Medicaid, and industry risk adjustment and quality regulations.
• Provide SME guidance to Product, Sales, and Account Management on RA policy and program implications.
• Partner with product teams to ensure solutions align with regulatory and audit requirements.
• Engage with industry groups (e.g., RISE, AHIP) to stay ahead of emerging trends.
• Translate regulatory changes into actionable product and roadmap recommendations.

Risk Adjustment Expertise

• Serve as the primary internal authority on CMS-HCC risk adjustment models, coding guidelines, and regulatory requirements.
• Monitor and interpret changes to Medicare Advantage risk adjustment methodology, RADV audit requirements, and encounter data submission rules.
• Provide guidance on ICD-10-CM documentation requirements and HCC coding accuracy to ensure product compliance.

Industry Engagement & Market Intelligence

• Maintain active involvement in industry organizations such as RISE (Risk Adjustment).
• Build and leverage relationships within the risk adjustment and quality community to gather market intelligence.
• Represent Cotiviti at industry conferences, webinars, and working groups as a thought leader.
• Synthesize market trends, competitive insights, and customer feedback into actionable product recommendations

Cross-Functional Collaboration

• Partner with Product Management to inform roadmap decisions based on regulatory changes and market needs.
• Support Sales and Solution Consulting teams with clinical expertise during customer engagements and RFP responses.
• Collaborate with Compliance and Legal teams on regulatory interpretation and risk mitigation strategies.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accomodation.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skill required.  This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

• Bachelor's degree in Healthcare Administration, Nursing, Health Information Management, or related clinical field.
• 5+ years of experience in Medicare Advantage risk adjustment, quality/HEDIS operations, or healthcare analytics.
• Deep knowledge of CMS-HCC risk adjustment models, RADV audits, and encounter data submission requirements.
• Strong understanding of Star Ratings methodology, and quality improvement programs.
• Experience interpreting CMS regulations, Federal Register notices, and healthcare policy changes.
• Demonstrated ability to translate complex regulatory requirements into business and product implications.
• Excellent communication skills with ability to present to both technical and executive audiences

Preferred Qualifications

• Clinical background (RN, CCS, CRC, RHIT, or similar certification).
• Active involvement in RISE community or similar industry organizations.
• Experience at a health plan, risk adjustment vendor, or healthcare technology company.
• Familiarity with both retrospective and prospective risk adjustment programs.
• Knowledge of ACA risk adjustment and Medicaid managed care quality requirements.
• Experience with healthcare data analytics and population health management tools.

Cognitive/Mental Requirement

• Communicating with others to exchange information.
• Problem-solving and thinking critically.
• Completing tasks independently.
• Interpreting data.
• Making timely decisions in the context of a workflow.

Physical Requirements and Working Conditions

• Must be able to provide high-speed internet access / connectivity and office setup and maintenance.
• Must be able to provide a dedicated, secure work area.
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access / connectivity and office setup and maintenance.

Base compensation ranges from $120,000 to $150,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. 

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 3/24/2026 

Applications are assessed on a rolling basis. We anticipate that the application window will close on 5/24/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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