Director, Risk Adjustment

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

📋 Description

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

• Establish performance metrics, operational cadence, roles and responsibilities, and resource allocation for accurate, complete, and compliant data submissions.

• Create and execute scalable prospective engagement and educational programs to enhance documentation and diagnosis reporting.

• Assist in member engagement strategies that are aligned with the improvement of health outcomes.

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

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

• Supervise the complete process of Medicare Advantage risk adjustment submissions, including EDS.

• Support ACA EDGE Server operations.

• Lead risk adjustment analytics, encompassing risk score and submission monitoring, reporting, and analytics.

• Work alongside Actuarial, Finance, and IT teams on reconciliation, forecasting, scenario modeling, regulatory impacts, and payment methodologies.

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

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

• Direct risk adjustment coding and operational workflows, including medical record retrieval, retrospective and prospective coding/validation, and adherence to coding guidelines.

• Lead initiatives in hiring, coaching, performance management, competency development, and succession planning.

• Manage departmental budgeting and vendor oversight, including vendor selection, contracting, and performance evaluation.

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

• Participate in internal committees and leadership meetings.

• Contribute to the annual Medicare Bid process.

• Actively engage as a member of managerial forums.

• Meet departmental and organizational performance and attendance standards.

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

• Perform additional duties as assigned.

• Report directly to the Vice President of Quality and Population Health.

⛳️ Requirements

• A 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 risk adjustment strategies, including both prospective and retrospective tools, data submission guidelines, and methods for engaging providers.

• Preferred experience in managing vendor relationships.

• Familiarity with pricing models across various lines of business and the ability to influence or manage value-based contracts with provider groups.

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

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

• A 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.

• Proficient in analyzing quantitative data from multiple sources using statistical modeling and advanced analytical techniques.

• Strong proficiency in SQL and other data analysis/reporting tools.

• Skilled in statistical software such as SAS and cloud-based platforms.

• Knowledge of performance measurement, cost analysis, database structures, relational concepts, and data architecture.

• Experience using Epic to enhance operational efficiency.

• Ability to identify problems, assess data, draw logical conclusions, and apply innovative problem-solving to complex business challenges.

• Excellent communication, facilitation, and presentation skills at the executive level.

• Capability to build trust and collaborative relationships with key stakeholders.

• Proficient in reading and comprehending both written and spoken English.

• Ability to communicate in a clear and effective manner.

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

• Must comply with privacy policies and HIPAA laws and regulations regarding the confidentiality and security of protected health information.

🏝️ Benefits

• Equal opportunity employment.

• Flexible work-from-home options.

• Ergonomically designed equipment.

• Opportunities for travel; approximately 10% travel required.