Director, Risk Adjustment

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

📋 Description

• Report to the Vice President of Quality and Population Health

• Develop and uphold an enterprise risk adjustment strategy, alongside its governance and control framework

• Establish performance metrics, operational cadence, roles, responsibilities, and resources necessary for compliant data submission

• Create scalable engagement and educational programs aimed at enhancing documentation and diagnosis reporting

• Support strategies for member engagement and wraparound services that align with improved health outcomes

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

• Collaborate with the Population Health Director to design annual education strategies

• Manage the complete Medicare Advantage risk adjustment submissions process, including EDS

• Assist with ACA EDGE Server activities

• Lead analytics related to risk adjustment, including monitoring, reporting, and analyzing risk scores and submissions

• Collaborate with Actuarial, Finance, and IT departments on reconciliation, forecasting, and scenario modeling

• Ensure readiness for audits and responses concerning MA and HHS RADV audits

• Oversee documentation standards, controls for medical record retrieval, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development

• Drive risk adjustment coding workflows, medical record retrieval, both retrospective and prospective coding/validation, and compliance controls

• Manage hiring, coaching, performance, productivity, competency development, and succession planning for roles related to risk adjustment

• Direct departmental budgeting, vendor selection, contracting, and performance management

• Cultivate partnerships across Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other teams

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

• Fulfill department and company performance and attendance standards

• Adhere to privacy policies and HIPAA confidentiality and security requirements

• Perform additional duties as assigned

⛳️ Requirements

• A minimum of 5 years of experience in a healthcare environment

• At least 3 years of experience specifically related to risk adjustment

• 3 years of experience in team management

• Thorough knowledge of prospective and retrospective risk adjustment tools, guidelines for data submission, and methods for provider engagement

• Experience in managing vendor relationships is preferred

• Familiarity with pricing models across various lines of business and value-based contracts is preferred

• Preferred experience with operations related to Medicaid, Medicare, and Commercial health plans

• Experience in strategic planning and system design within health plan environments is preferred

• A Bachelor's degree is required

• An advanced degree is preferred

• Extensive 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 techniques

• Proficiency in SQL, data analysis/reporting tools, statistical software such as SAS, and cloud-based platforms

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

• Experience using Epic is required

• Excellent executive-level communication, facilitation, and presentation skills

• Capability to read and comprehend written and spoken English

• Ability to communicate effectively and clearly

• Physical ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and engage in light lifting/carrying

🏝️ Benefits

• Equal opportunity employment

• Work in a general office environment with ergonomically designed equipment

• Travel is required approximately 10% of the time

• Engagement in internal committees and leadership meetings

• Opportunities for participation in managerial forums and leadership development