Director, Risk Adjustment

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

📋 Description

• Create and implement the enterprise risk adjustment strategy and governance framework across all relevant lines of business.

• Keep track of regulatory changes and developing risk adjustment methodologies, converting them into operational strategies and process enhancements.

• Supervise programs that ensure accurate diagnosis capture, medical record retrieval, chart review, coding, validation, and submission of risk adjustment data.

• Establish and uphold coding standards, policies, procedures, and quality criteria across all applicable lines of business.

• Manage coding quality assurance, secondary reviews, audits, corrective action processes, coder productivity, key performance indicators, and compliance with relevant CMS, state, federal, and organizational guidelines.

• Design and implement risk adjustment value-based programs in collaboration with key providers.

• Create and maintain an enterprise risk adjustment performance dashboard featuring key performance indicators that encompass impacts, coding accuracy, chart retrieval, documentation, submission, audit performance, and operational efficiency.

• Collaborate with actuarial and finance teams to quantify the effects of risk adjustment operations on risk scores and enhance projection accuracy for bids, pricing, forecasting, and accruals.

• Provide executive leadership with regular updates on performance, risks, opportunities, and suggested actions.

• Ensure the organization is prepared for CMS Risk Adjustment Data Validation (RADV) audits and regulatory assessments.

• Manage relationships with external vendors that assist with chart retrieval, coding, analytics, and other risk adjustment tasks.

• Lead, develop, and mentor risk adjustment leaders and teams, setting clear objectives, performance expectations, and professional growth plans.

⛳️ Requirements

• Bachelor’s degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field.

• Eight (8) years of progressive experience in healthcare risk adjustment, health plan operations, coding, clinical documentation, or a related discipline.

• Five (5) years of leadership experience.

• Exceptional communication, analytical, organizational, and executive leadership skills.

• Capability to manage multiple complex initiatives in a highly regulated and rapidly evolving environment.

• Specific experience in managing and leading risk adjustment programs in Medicare Advantage, Individual ACA, and/or Medicaid is preferred.

• Master’s degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field is preferred.

🏝️ Benefits

• Comprehensive health and wellness benefits.

• Professional development opportunities and continuing education support.

• A collaborative and supportive work environment.

• Competitive compensation package.