Risk Adjustment Resume Sample

6 votes
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Enrique Dach
810 Dudley Terrace,  San Francisco, CA
+1 (555) 773 7123

Work Experience

Manager, Hedis & Risk Adjustment
03/2016 - PRESENT
Chicago, IL
  • Under the direction of the Sr. Manager or Consultant-Risk Adjustment, and in collaboration with others on the RPM team, perform value-stream research, measurement, and model-building; develop strategies for, and calculations in support of RPM operations; and review the work of peers
  • Research, validate, and analyze data for monitoring and reporting, strategic & tactical support, and research & development projects
  • Draft reports and exhibits for review by manager or project leader
  • Recommend new ways of performing work tasks or projects, applying research and/or additional benchmarks to generate solutions
  • Work experience in risk adjustment, cost-benefit analysis, elimination, reduction, trend analysis, algorithm development, deduction, inference, recursion, or model-building or
  • Beginner-level proficiency in SAS
  • Develop comprehensive knowledge of Humana’s Medicare segment strategy and commitment to our Business Strategy - "The Integrated Care Delivery Model."
Mgr, Risk Adjustment
08/2012 - 10/2015
Detroit, MI
  • Develop comprehensive knowledge of Humana’s Medicare segment strategy and commitment to our Business Strategy: The Integrated Care Delivery Model
  • Uses strong critical thinking skills along with managed care, or physician office business knowledge to have insight and understanding of business concepts, tools and processes that are needed for making sound decisions in the contact of the company’s business
  • Understand Humana’s market position within the region and remaining current with Medicare industry developments and the evolving regulatory environment
  • Understand Humana’s marketplace for this region industry and Medicaid regulatory environment assuring all MRA functions are in compliance with CMS regulations
  • Manage team’s case load efficiently and effectively
  • Encourage growth and development among team members to support Humana’s goals and vision
  • Pursues Excellence:Seeks out learning, strives to develop and expand personally, and continuously helps others upgrade their capability to contribute to Humana
  • Leads Positively:Leads by example to cultivate a climate of motivation, positive energy and meaning in work. Assesses, selects, recognizes, develops, and empowers diverse talent
  • Participate as a team player by demonstrating support to peers, management and the department’s goals
Medicare Risk Adjustment
11/2007 - 03/2012
Philadelphia, PA
  • Provide leadership and direction for all functions related to MRA education and coding for Louisiana and Mississippi
  • Three main areas of responsible and oversight include: analysis in determining MRA opportunity, education with external physician groups and design of plan for chart retrieval and coding
  • Education and presentation to physician groups at risk meetings
  • Work with the finance team to identify and target providers for additional training on improving documentation, strengthening coding practices and ensuring coding accuracy
  • Experience working in or with Risk Adjustment
  • Abstract pertinent information from assigned medical records using ICD-9-CM, CPT and/or HCPCS codes
  • Provide management with input on provider performance from assigned audits and special projects
  • Document detailed chart audit findings including documentation errors; medical record errors; diagnosis errors as well as missed HCC opportunities in applicable audit tools on a daily basis
  • Ensure audit tools contain adequate evidence to support audit findings and reviews audit tools for accuracy and completeness


Franciscan University of Steubenville
2003 - 2007
Bachelor's Degree in Finance

Professional Skills

  • Experience working with mid or large-sized physician practices and or hospitals
  • Valid driver's license with good driving record and be able to drive within applicable state or locally with reliable transportation
  • Experience/Knowledge of MRA financial reporting
  • Experience to presenting to a senior level audience
  • Experience in Medicare ACO Programs, MACRA, MIPS & APM’s
  • Assures the final diagnoses as stated by the physician and other healthcare provider are valid and complete and of the highest level of specificity
  • Experience in health insurance

How to write Risk Adjustment Resume

Risk Adjustment role is responsible for travel, insurance, modeling, research, design, reporting, auditing, training, finance, government.
To write great resume for risk adjustment job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Risk Adjustment Resume

The section contact information is important in your risk adjustment resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Risk Adjustment Resume

The section work experience is an essential part of your risk adjustment resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous risk adjustment responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular risk adjustment position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Risk Adjustment resume experience can include:

  • Ensure all captured diagnoses is properly documented and supported within progress note according to CMS rules and regulations including but not limited to encounter date, legibility, proper provider signature and member identification requirements
  • Assist with reconciliation of invalid diagnosis list supplied by Other Departments
  • Report noncompliance issues detected through auditing
  • Attendance of additional provider training sessions based on departmental needs
  • Predictive modeling knowledge
  • Data mining knowledge

Education on a Risk Adjustment Resume

Make sure to make education a priority on your risk adjustment resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your risk adjustment experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Risk Adjustment Resume

When listing skills on your risk adjustment resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical risk adjustment skills:

  • Experience leading/ coordinating initiatives
  • Experience performing clinical data analysis
  • Experience Knowledge of Humana’s internal policies, procedures and systems
  • Familiarity with Humana’s various lines of business and productsReporting Relationships
  • Adheres to Official Coding Guidelines
  • Provide one on one provider training and audit sessions as requested by management

List of Typical Skills For a Risk Adjustment Resume


Skills For Manager, Hedis & Risk Adjustment Resume

  • This role has 10-15 direct reports, and it reports to the Manager
  • Act as a liaison between operational and functional areas, sales, group executives, and the internal support team to identify and address barriers cross-functionally
  • Assist with implementation of risk adjustment strategy in conjunction with Corporate Risk
  • Adjustment department and plan QI and Provider Services Directors
  • Assigns and sequences ICD/CPT/HCPCS codes to diagnoses and procedures from documented information in the medical record

Skills For Director of Risk Adjustment Resume

  • Reviews medical records to identify secondary complications and co-morbid conditions
  • Codes and abstracts all necessary information with most accurately describes each documented diagnoses and procedures
  • Provide support, education and training related to, quality of documentation, level of service and diagnosis coding consistent with established coding guidelines and standards
  • Knowledge State of Federal risk adjustment models
  • Knowledge of Medicare Advantage, Medicare Part D, Medicaid, or Qualified Health Plans
  • Progressive work experience in a managed care environment, including prior responsibility for directing strategic planning activities, data analysis,and reporting for government sponsored (regulated) managed care programs (Medicare/Medicaid)
  • Experience successfully managing and leading functional teams with educational, reporting, compliance and documentation responsibilities; prior experience managing both “onsite” and “remote” teams would be beneficial to this role

Skills For Mgr, Risk Adjustment Resume

  • Reputation for seeing the “big picture” (i.e., multiple integrated activities of a complex business operation), while concurrently managing complex projects and meeting specific and detailed requirements for integrity and accuracy of data reporting
  • Prior experience in a clinical environment with working knowledge of medical terminology and responsibility for coding guidelines, clinical quality, data collection tools/technology and regulations is highly desired
  • Prior operational leadership experience within an entrepreneurial business environment is desired
  • Prior experience and commitment to a performance review and feedback process
  • Experience working with regulatory agencies (CMS)

Skills For Risk Adjustment Operational Lead Resume

  • Progressive work experience in a managed care environment, including prior responsibility for directing strategic planning activities, data analysis, and reporting for government sponsored (regulated) managed care programs (Medicare/Medicaid)
  • Reputation for seeing the “big picture” (i.e., multiple integrated activities of a large business operation), while concurrently managing complex projects and meeting specific and detailed requirements for integrity and accuracy of data reporting
  • Work with Medical Management to provide confidential feedback on special audits on as needed basis
  • Research and provide courteous, accurate and timely response to inquires by providers as related to HCC Risk Adjustment projects and reports
  • Serve as a resource for internal and external customers to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines and regulatory requirements
  • Work with Health plans to ensure appropriate status information for member is reflected
  • Perform various audits and special projects as assigned by management

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