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Position Summary
We have an outstanding opportunity for an enthusiastic team player to lead a suite of market focused Risk Adjustment Programs  for a portfolio of Aetna Better Health Medicaid Plans.  Reporting to the Lead Director of Medicaid Risk Adjustment, the Market Manager will work closely with cross-functional leadership across the Medicaid business to establish and champion a local market culture committed to revenue integrity excellence. This position will require a comprehensive understanding of risk adjustment, with the ability to speak to and present on all activities (programs, analysis, encounter data submission and quality assurance) across revenue integrity processes related to risk adjustment (RA) focused on complete and accurate diagnosis capture and reporting. This position will drive RAF performance through the delivery of measurable programs with actionable solutions.

Market Lead & Performance Management

• Act as a face of Revenue Integrity across internal market teams.
• Lead market meetings reporting out to market executive leadership on a monthly basis, accountable for key takeaways from meetings.
• Investigates operational issues that impact market performance – work with business partners to implement solutions.
• Track deliverables and identify barriers in market engagement in conjunction with implementing resolutions.
• Assist with development of educational material to support market intelligence.
• Engage with market clinical team, care management team, member services team; attend market level meetings as appropriate.

Data Analysis & Reporting

• Work closely with the Informatics team to review requirements, dashboards, reports including any enhancements.
• Utilize data analyses using national tools in conjunction with the corporate lead to identify areas of opportunity.
• Produce and present dashboards specific to Medicaid Revenue Integrity efforts at various governance, market, and executive leadership meetings.

3. Strategy & Execution

• Monitors program or programs  that are jointly accountable for risk adjustment strategy, performance, and results within a designated market(s).
• Responsible for identifying and recommending nuanced market risk adjustment strategies and collaboratively executing tactics to focus, maximize and achieve market success, including market referrals.
• Execute on local market strategies to drive correctness, completeness, accuracy, and timeliness of risk score performance.
• Collaborate on market specific strategies that drive member engagement in risk adjustment programs.
• Stay abreast of regulatory changes and leading risk adjustment practices and tools to maximize the effectiveness and efficiency of the team.
• Partner with segment product, sales, network, clinical teams to implement processes aimed at strengthening member and provider engagement of Revenue Integrity programs resulting in improved outcomes.

Required Qualifications
3+ years business experience or project management in relevant field

Must have knowledge of health insurance regulatory and contractual requirements

Self-starter who demonstrates initiative and displays a high energy level.

Must have strong communication and/or presentation skills.

Preferred Qualifications

Certified Professional Coder (CPC)

Certified Risk Adjustment Coder (CRC)

Prior experience in Risk Adjustment field/Medicaid

Education

Bachelor’s Degree required from an accredited four year college or university or equivalent work experience in lieu of a degree.

Pay Range

The typical pay range for this role is:

$54,300.00 - $145,860.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/31/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.