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Supervisor Strategic Risk Adjustment and Quality

April 30, 2026

<h2>Company :</h2>Highmark Inc.<h2>Job Description : </h2>JOB SUMMARYThis job is responsible for developing plans and managing activities in support of Risk Adjustment and Quality/HEDIS. Directs the daily activities of direct reports supporting Risk Adjustment Coding and Quality/HEDIS. Assesses viability of current direction/projects/operations and recommends strategies and tactics to satisfy current and future business needs. Actively seeks and identifies opportunities for improvement. Implements strategic and tactical improvements to the Risk Adjustment Coding and Quality/HEDIS processes. Manages information that will ensure accurate and efficient projects. Responsible for working with appropriate departments in the areas of risk adjustment, compliance, process improvement and member/provider satisfaction for all product lines. Recommend and/or implements process improvements related to the potential of quality medical care and service. Serves as a resource regarding government and regulatory audits, accreditation standards, and continuous quality improvement principles. Co-ordinates audit and accreditation activities on behalf of the organization. Oversees the Performance of special studies per audits, conducting provider office visits and medical records reviews. Conducts specialized provider office visits for provider education on Risk Adjustment and Quality/HEDIS measures. Oversees the development and implementation of risk adjustment and risk mitigation education related to medical record documentation, risk adjustment, Quality/HEDIS. Review of provider office/entity process for appropriate submission of ICD10, CPT, and HCPCs codes according to government and coding guidelines. ESSENTIAL RESPONSIBILITIES<ul><li>Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.</li><li>Provide day-to-day managerial oversight for staff responsible for Risk Adjustment coding and Quality/HEDIS activities. Ensure continuous improvement of processes and delivery of results within assigned area. Encourage innovation and focus resources, including staff not under direct managerial control, to ensure successful delivery of desired results. Optimize the use of resources in assigned area using proven resource management techniques. </li><li>Contribute to the department’s strategic planning efforts by identifying tactical opportunities for improvement, recommending solutions, and developing materials especially directed at Risk Adjustment, Quality/HEDIS, and Medical Record Documentation projects related to the development and implementation of educational opportunities. Oversee development and execution of processes that will support the capture of complete and accurate diagnosis coding. Oversee the development and implementation of complete, accurate, and fair QA standards for all medical coders. Maintain Productivity and team QA scores and report to leadership.</li><li>Oversee the teams’ processes to conduct multiple type of audits, government and internal, identify gaps, repeating issues and communicate results in provider office sites with data analysis from office site and/or medical record reviews to (a) continually improve the care, service to members and patient satisfaction; (b) coordination with other Highmark programs for credentialing, quality improvement programs, value based programs, care management programs, to achieve high caliber results, and (c) ensure medical records meet regulatory requirements. Consults with providers as needed to ensure identified gaps, or chart deficiency trends are outlined, communicated, discussed and provider staff trained on correct procedures.</li><li>Participate in initiatives requiring cross-functional, matrix relationships. These initiatives may involve staff in different departments or business units within the organization, or vendors and/or strategic business partners. Assess the impact of potential or actual regulatory changes impacting the assigned area. Ensure ongoing compliance in all activities within the assigned area. Oversee the development and manage process improvement initiatives to include detailed data analysis, process analysis, report generation and documentation. </li><li>Other duties as assigned or requested.</li></ul> EDUCATION Required<ul><li>Bachelor's Degree in a Health related field or current state RN/LPN license</li></ul>Substitutions<ul><li>6 years of combined experience with RN/LPN, Risk Adjustment, HCC coding, medical coding/billing HEDIS and/or healthcare related management</li></ul> Preferred<ul><li>None</li></ul>EXPERIENCE Required<ul><li>6 years of combined experience with RN/LPN, Risk Adjustment, HCC coding, medical coding/billing HEDIS and/or healthcare related management</li></ul>To Include:<ul><li>3 years with government markets and working within all Compliance and Coding guidelines</li><li>1 year in a management or leadership role</li></ul> Preferred<ul><li>3 years in a clinical nursing role, in a hospital or office setting (RN or LPN)</li><li>3 years in the Health insurance field </li><li>3 years of mentoring others </li><li>1 year of Project management </li><li>1 year with Total Quality Management (TQM) concepts, techniques, process and outcome measurements experience</li><li>1 year working with Healthcare Effectiveness Data and Information Set (HEDIS)</li></ul> LICENSES or CERTIFICATIONS Required (any of the following)<ul><li>Certified Professional Coder (CPC)</li><li>Certified Coding Specialist (CCS)</li><li>Registered Health Information Administrator (RHIA)</li><li>Clinical Research Coordinator (CRC)</li></ul>Preferred<ul><li>Licensed Practical Nurse (LPN)</li><li>Registered Nurse (RN)</li></ul> SKILLS<ul><li>Excellent verbal communication skills </li><li>Professional manner and excellent written communication skills, including a familiarity with a variety of writing styles</li><li>Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)</li><li>Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data</li><li>Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution</li></ul> Language (Other than English):NoneTravel Requirement:0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-basedTeaches / trains others regularlyFrequentlyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products/services (sales employees)NeverPhysical work site requiredNoLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsRarelyDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum:$86,400.00Pay Range Maximum:$138,600.00Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.For accommodation requests, please contact HR Services Online at <a href="mailto:HRServices@highmarkhealth.org" target="_blank" rel="noopener noreferrer">HRServices@highmarkhealth.org</a><a href="https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib_458575_QLVK9_1769448333304228022_1769448333396/1769448333396.pdf" target="_blank" rel="noopener noreferrer">California Consumer Privacy Act Employees, Contractors, and Applicants Notice</a>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...