The Managed Care Manager is responsible for the operational management and performance of the organization's managed care and value-based programs. This position oversees initiatives related to payer performance, risk adjustment, HCC/RAF capture, quality measures, utilization management, care management, and value-based reimbursement. The Manager works closely with providers, clinic leadership, clinical staff, Business Office, referral teams, payers, and executive leadership to improve patient outcomes while maximizing performance under managed care and risk-based contracts.
The position serves as a key operational liaison between the organization and contracted health plans and is responsible for translating payer requirements and performance data into actionable strategies for providers and operational teams.
AND RESPONSIBILITIES Managed Care & Value-Based Contract Performance Manage the day-to-day operational performance of managed care, Medicare Advantage, Medicaid managed care, ACO, and other value-based arrangements. Maintain a comprehensive inventory of managed care and value-based contracts, populations, performance requirements, and reporting deadlines. Monitor contract performance including PMPM revenue, shared savings, quality incentives, risk-adjustment revenue, utilization, medical cost trends, and other value-based payments.
Identify opportunities to improve financial and clinical performance within managed care contracts. Coordinate implementation of new payer programs, contract requirements, and performance initiatives. Collaborate with executive leadership and Finance to evaluate managed care performance and revenue opportunities.
HCC / RAF & Risk Adjustment Oversee HCC and risk-adjustment initiatives across participating providers and clinics. Monitor RAF scores, suspect conditions, recapture rates, documentation opportunities, and coding completion. Coordinate prospective and retrospective chart reviews as appropriate.
Work with providers and clinical staff to improve accurate documentation of chronic conditions. Develop provider education regarding documentation specificity, MEAT criteria, annual recapture, and risk-adjustment requirements. Monitor provider-level HCC performance and develop corrective action plans when targets are not achieved.
Ensure risk-adjustment activities comply with CMS and payer requirements. Quality / HEDIS / STAR Performance Oversee performance improvement initiatives for HEDIS, STAR, preventive care, and payer-specific quality measures. Monitor quality gaps and coordinate outreach strategies for gap closure.
Develop provider, clinic, and payer-level quality dashboards. Partner with clinical teams to improve preventive screenings, chronic disease management, medication adherence, annual wellness visits, and other quality measures. Analyze performance trends and identify areas requiring operational intervention.
Coordinate payer chart requests, supplemental data submissions, and medical-record reviews. Population Health & Care Management Support development and oversight of population health programs for high-risk and chronically ill populations. Coordinate initiatives involving Chronic Care Management (CCM), Transitional Care Management (TCM), Principal Care Management (PCM), Annual Wellness Visits (AWV), and other population health programs.
Identify high-risk populations requiring additional clinical intervention. Coordinate with providers and clinical teams to improve continuity of care and reduce avoidable utilization. Support outreach strategies for patients with chronic disease and preventive-care needs.
Utilization Management Monitor utilization trends including emergency department visits, hospital admissions, readmissions, observation stays, specialist utilization, and other high-cost services. Identify potentially avoidable utilization and opportunities for intervention. Develop reports identifying high-risk and high-utilizing patients.
Collaborate with primary care providers, specialists, care management teams, and hospital departments to improve care coordination. Assist in developing strategies to reduce avoidable emergency department utilization and hospital readmissions. Monitor referral patterns and network utilization when applicable.
Provider Performance & Education Develop provider-level managed care scorecards. Meet with providers and clinic leadership to review performance. Provide education regarding HCC/RAF, HEDIS, STAR measures, utilization, documentation, and value-based care.
Identify provider performance opportunities and develop improvement plans. Support provider incentive and bonus programs tied to quality, risk adjustment, utilization, access, and managed care performance. Data Analytics & Reporting Develop and maintain dashboards and reports measuring managed care membership/panel size, PMPM revenue, RAF scores and HCC recapture, HEDIS and STAR performance, quality gap closure, Annual Wellness Visit completion, emergency department utilization, admissions and readmissions, high-risk patient populations, referral and specialist utilization, provider performance, care-management enrollment and outcomes, and managed care incentive and bonus revenue.
Present performance results and recommendations to executive leadership, providers, committees, and other stakeholders. LEADERSHIP RESPONSIBILITIES Supervise assigned Managed Care, Population Health, Quality, or Care Management staff as applicable. Establish departmental goals, workflows, productivity standards, and performance expectations.
Provide coaching, education, and ongoing staff development. Coordinate cross-functional projects involving clinics, providers, Business Office, Referrals, Scheduling, Quality, and hospital departments. Lead implementation of managed care improvement initiatives.
Promote accountability for quality, financial, and operational outcomes. Qualifications Education Bachelor's degree in Healthcare Administration, Business Administration, Nursing, Public Health, Health Information Management, or related field preferred. Relevant healthcare leadership and managed care experience may be considered in lieu of degree requirements as permitted by organizational policy.
Experience Minimum 3–5 years of healthcare operations, managed care, population health, quality, revenue cycle, or value-based care experience. Experience working with Medicare Advantage and/or Medicaid managed care strongly preferred. Experience with HCC risk adjustment, RAF, HEDIS, STAR measures, and population health preferred.
Previous supervisory or management experience preferred. Experience working with physicians and advanced practice providers strongly preferred. Licensure/Certification RN or LVN licensure is preferred but not required when appropriate experience and education are demonstrated.
Relevant certifications in healthcare quality, managed care, coding, population health, or healthcare administration are a plus. KNOWLEDGE, SKILLS & ABILITIES Strong knowledge of managed care and value-based reimbursement. Understanding of Medicare Advantage and Medicaid managed care.
Knowledge of HCC/RAF risk adjustment. Understanding of HEDIS and STAR quality programs. Understanding of utilization and population health management.
Strong analytical and data-interpretation skills. Ability to develop and interpret operational dashboards. Strong Excel and reporting skills.
Understanding of clinical workflows and physician practice operations. Ability to communicate effectively with physicians, executives, payers, and frontline staff. Strong project-management and organizational skills.
Ability to translate complex payer requirements into operational workflows. Ability to identify financial and clinical improvement opportunities. Ability to manage multiple initiatives and deadlines simultaneously.
POSITION EXPECTATIONS The Managed Care Manager is expected to maintain a strong understanding of evolving CMS, payer, and value-based care requirements and proactively identify opportunities to improve organizational performance. Success in this position requires the ability to connect clinical quality, utilization, risk adjustment, operational performance, and financial outcomes into a coordinated managed care strategy that improves both patient outcomes and organizational sustainability.
Day
4 Year Degree