Manager Risk Adjustment Operations

Workforce Classification:

Hybrid

Join Our Team: Do Meaningful Work and Improve People’s Lives 

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we are fostering a culture that emphasizes employee growth, collaborative innovation, and inspired leadership. We are dedicated to creating an environment where employees can excel and where top talent is attracted, retained, and thrives. As a testament to these efforts, Premera has been recognized on the 2025 America's Dream Employers list. Newsweek honored Premera as one of America's Greatest Workplaces, America's Greatest Workplaces for Inclusion, and America's Greatest Workplaces For Mental Well-Being, Forbes ranked Premera among America’s Best Midsize Employers for the fourth time.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog:  https://healthsource.premera.com/.

Are you an experienced leader with a strong background in Risk Adjustment Operations? We invite you to join our team as the Manager of Risk Adjustment Operations, where you will lead our core operations team. In this role, you will be responsible for overseeing submissions, audits, and compliance activities across our Individual, Small Group, and School Employees Benefit Board (SEBB) lines of business as well as all medical record retrieval for risk adjustment and some retrieval support for quality/HEDIS.

As a key member of our team, you will develop and execute strategies aimed at ensuring accurate submissions, error remediation, and priority claims processing. You will collaborate effectively with various departments and vendors to guarantee compliant, timely, and efficient tactical deployment. Additionally, you will manage vendor relationships and oversee vendor management processes. Your responsibilities will include directing the end-to-end medical record retrieval program, involving remote EMR access from multiple provider systems and issuing direct letter requests to providers in support of Quality and Risk Adjustment initiatives.

Join this mission driven and passionate team in our pursuit of making healthcare work better.

What you’ll do:

• Supervise a team of individual contributors and a Medical Record Retrieval Team Lead, as well as seasonal contingent workers. This includes hiring, coaching, and providing performance feedback.
• Ensure compliance with CMS regulatory requirements and manage claims, enrollment, and data submissions.
• Oversee compliance with WA Health Care Authority submission requirements.
• Manage annual deliverables and timelines for HHS-RADV audits, including executive leadership reviews and approvals.
• Support MARADV audit deliverables and timelines, and other ACA, MA, and SEBB audits in partnership with Compliance.
• Manage medical record retrieval efforts for various lines of business, ensuring records are routed to coding queues and improving retrieval program efficiency.
• Perform vendor management and contracting activities, including sourcing, negotiation, implementation, and oversight of vendor services.
• Conduct program reporting on project status, risks, and outlook for senior leadership, and recommend action steps based on analytic results.
• Ensure risk adjustment submissions and audit processes are compliant with regulatory requirements and not impacted by enterprise changes.
• Implement management control processes to maintain team and vendor budgets within approved amounts.

What you’ll bring:

• Bachelor's degree in business, healthcare, or systems management or related field or four (4) years of work experience (Required)
• Eight (8) years of experience managing complex projects with inter-related Systems, Process and Business requirements (Required)

Preferred Qualifications:

• One (1) year supervisory experience
• Five (5) years of experience in a health plan or related field
• Experience with quality measures, inclusive of HEDIS, CAHPS, and HOS
• Experience with provider community and market anomalies, as applicable
• Experience with claims payment systems and processes

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• Medical, vision, and dental coverage with low employee premiums.

• Voluntary benefit offerings, including pet insurance for paw parents.

• Life and disability insurance.

• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.

• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.

• Generous paid time off to reenergize.

• Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.

• Employee recognition program to celebrate anniversaries, team accomplishments, and more.

For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.

• Commuter perks make your trip to work less impactful on the environment and your wallet.

• Free convenient on-site parking.

• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.

• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.

• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.

• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

National Plus Salary Range:

$109,000.00 - $185,300.00

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.