Director, Risk Adjustment

This is a fully remote position, open to applicants in Florida.

📋 Description

• Develop and uphold an enterprise risk adjustment strategy, governance structure, and control framework.

• Establish performance metrics, operating schedules, roles, responsibilities, and resources for compliant data submissions.

• Create scalable engagement and educational programs to enhance documentation and diagnostic reporting.

• Assist in member engagement strategies that are aligned with improved health outcomes.

• Supervise provider feedback, insights from Annual Wellness Visits, and education for the Coding team.

• Manage Medicare Advantage risk adjustment submissions, including EDS, and support ACA EDGE Server activities.

• Direct risk adjustment analytics, which includes monitoring risk scores and submissions, reporting, analytics, forecasting, and scenario modeling.

• Ensure readiness and response for audits, both internal and external, including MA and HHS RADV audits.

• Oversee risk adjustment coding operations, medical record retrieval, retrospective and prospective coding/validation, and compliance controls.

• Handle hiring, coaching, performance evaluation, productivity, competency development, and succession planning for risk adjustment positions.

• Lead departmental budgeting, including vendor selection, contracting, and performance management.

• Establish partnerships with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other internal teams.

• Engage in strategic initiatives, internal committees, leadership meetings, and the annual Medicare Bid process.

• Meet the performance and attendance expectations of the department and company.

• Adhere to PacificSource privacy policies and HIPAA laws and regulations.

• Execute additional duties as assigned.

⛳️ Requirements

• Minimum of 5 years of experience in a healthcare environment.

• At least 3 years of experience directly related to risk adjustment.

• 3 years of experience in team management.

• Extensive knowledge of prospective and retrospective risk adjustment tools, data submission guidelines, and provider engagement strategies.

• Experience in managing vendor relationships is preferred.

• Familiarity with pricing models across various lines of business and value-based contracts with provider groups.

• Preferred experience with Medicaid, Medicare, and Commercial health plan operations.

• Bachelor’s degree is required.

• An advanced degree is preferred.

• Comprehensive knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards.

• Strong skills in quantitative data analysis, statistical modeling, and advanced analytical methods.

• Proficiency in SQL, data analysis/reporting tools, and statistical software such as SAS, along with experience in cloud-based platforms, performance measurement, and cost analysis.

• Understanding of database structures, relational concepts, data architecture, and Epic.

• Executive-level communication, facilitation, and presentation skills.

• Ability to read and understand written and spoken English.

• Capability to communicate clearly and effectively.

• Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and lift/carry files and business materials.

🏝️ Benefits

• Equal opportunity employment.

• Travel required approximately 10% of the time.

• General office environment equipped with ergonomically designed equipment.