Risk Adjustment Provider Performance Consultant

The Role

The Risk Adjustment Provider Performance Consultant role is a strategic, high-impact individual contributor role responsible for designing and executing comprehensive provider engagement and improvement strategies. Reporting to the Senior Director of Risk Adjustment and Analytics, this role serves as a principal subject matter expert and consultative partner to provider networks, ensuring complete and accurate medical record documentation.

Acting as the critical bridge between clinical documentation, data analytics, and network strategy, this role will cultivate collaborative partnerships with provider clinic managers, billing leads, and coding supervisors to drive hands-on, localized performance improvement initiatives. Without direct people management responsibilities, this leader will rely on cross-functional influence, advanced data insights, and deep regulatory expertise to integrate risk adjustment efforts into the organization's broader value-based care and quality objectives.

Responsibilities

• Program & Strategy Leadership:Direct and independently manage the overarching provider engagement strategy for risk adjustment. Define strategic objectives, core workflows, and key performance indicators (KPIs) for network-wide provider outreach and engagement.
• Strategic Provider Partnerships:Serve as the principal escalation point and strategic consultant for key provider group leadership regarding risk adjustment performance, documentation practices, and coding compliance.
• Data-Driven Strategy & Analytics:Partner closely with the Data & Analytics team to interpret complex provider performance data. Utilize advanced analytics to independently identify high-value intervention opportunities, pinpoint documentation gaps, and segment provider networks for targeted outreach.
• Coding Support & Opportunity Optimization:Proactively identify and action specific coding and documentation opportunities across the provider network. Provide advanced, consultative coding support and tailored feedback on complex cases to clinical partners, ensuring accurate capture of patient acuity and strict adherence to the latest CMS HCC and HHS coding guidelines.
• Matrix Leadership & Cross-Functional Integration:Forge strategic alignment with Provider Contracting, Health and Medical Management, and Quality teams. Influence and guide cross-functional stakeholders to seamlessly integrate risk adjustment goals into broader value-based care contracts and incentive programs.
• Executive Reporting:Design and present executive-level dashboards tracking provider engagement metrics, the ROI of strategic interventions, coding accuracy improvements, and overall network performance against enterprise targets.
• Regulatory Strategy & Compliance:Act as a principal subject matter expert on CMS and HHS legislative and regulatory changes. Translate federal policy shifts into strategic operational plans and proactive communications for both internal leadership and provider partners.
• Initiative Execution:End-to-end ownership of multi-year provider-facing risk adjustment initiatives, ensuring flawless execution, continuous monitoring, and alignment with enterprise financial and compliance objectives.

Qualifications

Education

• Bachelor's Degree in Healthcare Administration, Business, Nursing, Health Information Management, or related field.

• 7+ years of relevant experience in lieu of a Bachelor's Degree

Experience & Skills

• 7+ yearsof extensive experience in Medicare Advantage risk adjustment, provider network management, provider education, or clinical documentation improvement (CDI) within a health plan or large provider group.
• 5+ yearsof progressive experience in strategic program management, matrix leadership, or advanced provider engagement, with a proven track record of driving large-scale initiatives without direct authority.
• Executive Presence:Exceptional communication and presentation skills, with the ability to influence, consult, and persuade clinical leaders, executive stakeholders, and cross-functional partners.
• Analytics Acumen:Strong ability to independently interpret complex performance data, collaborate with analytics teams, and translate findings into targeted, strategic provider interventions.
• Strategic Integration:Deep understanding of value-based care models, provider contracting, and how risk adjustment intersects with HEDIS/Quality metrics.
• Technical Knowledge:Mastery of ICD-10-CM guidelines, CMS HCC methodologies, and official medical record documentation standards.

Certifications

• AAPC Certified Risk Coder (CRC) -Required
• Certified Professional Coder (CPC)orCertified Coding Specialist (CCS / CCS-P) -Required
• Certified Documentation Improvement Practitioner (CDIP)orCertified Clinical Documentation Specialist (CCDS) -Strongly Preferred
• Active Clinical License (e.g., RN, BSN) -Desired

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.