PHO Risk Adjustment Manager, 17909

MelroseWakefield Healthcare Woburn, MA

About the Job

Company Description

MelroseWakefield Healthcare is a coordinated system of hospitals, physician practices and community-based services providing care for communities throughout north suburban Boston. We are distinguished by the range of clinical care and services we provide locally for the continuum of care in clinical collaboration with Tufts Medical Center, as well as an affiliation with the Lawrence Memorial. Our focus is simple: a better approach to providing health care, we bring together top-quality primary, emergency and specialty care, locally. Everything you and your family need, right in your neighborhood to be your best healthy.

Job Description

The Hallmark Health PHO Risk Adjustment Manager will lead and grow an emerging coder team as well as perform coder related functions as part of the Coding Program for PHO community providers.  This individual will report to the Director of Provider Services and work collaboratively with others in the organization, including Medical Directors, the EMR team, and PHO staff to drive the overall strategy.  The PHO Risk adjustment Manager will mentor and directly/indirectly manage other member(s) of the risk adjustment team (reporting relationship contingent on the management experience/skills of the individual). This individual will have a solid understanding of risk based financial models, such as Medicare Advantage, Medicare Next Gen, Managed Medicaid and Commercial budget models (i.e., BCBS AQC Model) and how risk capture impacts financial results within these models. The individual will implement, support and develop various aspects of this program, including clinician training, program reporting, and will play a role in shaping the organizational structure as the Coding Program continues to evolve. A key aspect of the role is the development, customization and presentation of risk adjustment educational principals and program results to PHO providers as appropriate for different providers and practice staff (MDs, NP/PAs, medical billers, etc.).  As a leader on the team, the role will play a quality assurance function and help drive risk adjustment standards, policies and procedures based on the most recent industry guidelines.  Position responsibilities include overseeing risk capture performance, reporting and assisting with the following:  coding, abstracting and analyzing/reviewing medical records for the PHO risk adjustment programs to ensure proper medical diagnoses are coded appropriately and that the members’ medical record documentation supports the codes accurately in accordance with CMS, CPT and ICD.10 guidelines.




Minimum requirements include:

  1. one of the following professional certifications from AHIMA or AAPC: Certified Professional Coder (CPC), Certified Coding Specialist (CCS or CCS-P), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC)
  2. AND a Certified Risk Adjustment Coder certification (CRC).
  3. A Certified Risk Adjustment trainer certification is a plus.
  4. Prefer Bachelor’s Degree in Healthcare or related field; Master’s degree is a plus.


Requires at least 6-10 years in medical claims coding, including coding abstraction, and advanced knowledge of coding rules within the risk adjustment forum required.
3-5 years progressively responsible leadership experience and/or previous experience working in an educational / training role preferred.

Experience working with CMS, risk adjustment, health insurers and medical providers strongly preferred.



  • Presentation/training abilities and experience required. 
  • Excellent communication and interpersonal skills, including ability to interact professionally with all levels of management and clinical teams
  • Expertise in risk adjustment and risk adjustment methodologies
  • Advanced knowledge of ICD.10 coding required
  • Familiarity with EMR technology.  Experience with GE Centricity and EPIC preferred. Experience with Clinnovations / Nordic / similar products a plus.
  • Expert knowledge of medical terminology and abbreviations and disease, illness and injury processes
  • Expertise in CMS HCC risk adjustment model.  Managed Care experience preferred.
  • Knowledge of Microsoft Office, including Word, Powerpoint and Excel required.  Knowledge of Access desirable.
  • Excellent written and verbal communication skills


This position is a remote position with the expectation of flexibility for the occasional in person training/ other meeting. 

Reliable transportation is necessary. The HHPHO office is located in Woburn with occasional travel to Provider Offices. Frequent standing & walking, and lifting of 5-10 lbs. Work includes meetings outside of normal business hours (such as early morning and/or evening clinician meetings to accommodate educational sessions and meeting with clinicians).


Additional Information

All your information will be kept confidential according to EEO guidelines.


Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. MelroseWakefield Healthcare reserves the right to modify position duties at any time, to reflect process improvements and business necessity.


Please note that effective October 1, 2021, as a condition of employment at MelroseWakefield, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.