Manager, Risk Adjustment (Operations) -Remote at Medica

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The Manager, Risk Adjustment works with various departments at Medica to ensure timely, accurate, and complete risk adjustment data submissions (also known as EDGE Server submissions) in compliance with CMS requirements and the Affordable Care Act (ACA) health care reform law. This individual stays current on all EDGE Server submission and Risk Adjustment Data Validation (RADV) audit requirements, oversees and coordinates all submission and audit activities, and leads process improvement efforts to increase data accuracy.

The Manager ensures that processes and policies are followed to produce high quality results. This individual coordinates projects that may involve/impact multiple areas of the organization, monitors progress toward goals, and assists in project prioritization and resource planning. This is a team leader position that will manage 2-3 analysts. The team is responsible for managing, measuring, and validating the ACA market data submissions to ensure complete and accurate capture of membership and claim data. The manager will work closely with counterparts in Medica IT to oversee the EDGE server system and data submission process including communicating requirements for CMS changes, testing and validating changes, and monitoring/measuring submission results.


  • Bachelor's Degree Required; background in health informatics, business analysis programming, IT, business administration, finance, quantitative techniques or a related discipline
  • 5 years of experience required in progressively responsible analytical data management roles in a complex operational setting or consulting role
  • Understanding of claims systems and processing, EDI files, and/or experience working with large data sets, CMS, health insurers and/or medical providers in a technical capacity strongly preferred.
  • Experience with internal and external audits strongly preferred
  • Healthcare experience required; CMS data submission knowledge strongly preferred
  • Strong time management and ability to meet regulatory timelines
  • Ability to interact in a professional manner with all levels inside and outside of the organization to maintain constructive and effective working relationships

Skills and Abilities:

  • Leadership skills (direct reports 2-3)
  • Strong relationship building, communication, and organization skills
  • Proven ability to work cross-functionally required
  • Demonstrated experience leading projects, researching and conducting data analysis, and influencing process improvement across departments and with our vendor partners
  • Advanced level proficiency in MS Office products (Word, Excel, and PowerPoint)
  • Strong query language skills (SAS, SQL) used to navigate a complex data landscape and manipulate large data sets.
  • Understanding of data warehousing concepts (star schema, joins, etc.), data quality methods
  • Claim platform experience preferred
  • Strong attention to detail with the ability to articulate and implement change

This position requires COVID-19 vaccination per Medica's Employee COVID-19 Vaccination Policy. If you are hired, you would be expected to be fully vaccinated for COVID-19 prior to starting the position, unless a medical or religious exemption is needed. Medica is an Equal Opportunity Employer and provides reasonable accommodations in compliance with the ADA and Title VII.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
More Information on Medica
Medica operates in the Healthtech industry. The company is located in Minnetonka, MN and Minnetonka, MN. Medica was founded in 1975. It has 2973 total employees. It offers perks and benefits such as Flexible Spending Account (FSA), Disability insurance, Dental insurance, Vision insurance, Health insurance and Life insurance. To see all 4 open jobs at Medica, click here.
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