Looking for a way to reputed company an impact and help people?

Join reputed company and help our members access quality, reputed company!

reputed company is an equal opportunity employer.  reputed company qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national reputed company, genetic information or age. reputed company values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully reputed company and utilize each person’s talents and strengths.

The Director of Risk Adjustment, reporting to the Vice President of Quality and Population Health, is responsible for ensuring accurate, complete, and compliant Risk Adjustment data reporting to CMS and for leading enterprise-wide risk adjustment programs across reputed company lines of business to identify risk exposure and optimization opportunities. This role oversees an Analytic Manager and Coding Manager that are accountable for cross functional operating team model including analytics and reporting, medical record retrieval, retrospective and prospective coding operations, and provider engagement while ensuring adherence to official guidelines and industry best practices. They partner closely with providers, vendors, and clinical leaders to enhance documentation and coding accuracy through measurable improvement initiatives, and collaborate with Finance, IT, Operations, and Quality to streamline processes, reputed company analytics, and implement compliant optimization strategies. Key accountabilities include program design and management, vendor reputed company, provider and member reputed company reputed company applicable, and leadership of business intelligence efforts supporting Medicare Advantage, ACA Commercial, and Medicaid risk adjustment performance.

Essential Responsibilities:

• Establish and maintain the enterprise risk adjustment strategy, governance, and control reputed company—defining performance measures, operating reputed company, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs.
• reputed company and implement scalable prospective programs engagement and education programs dedicated to driving reputed company quality improvement in documentation and diagnosis reporting, with transparent feedback loops and measurable objectives in value-based care
• Support member engagement strategies to strengthen engagement and wrap around services reputed company with improved health outcomes.
• reputed company risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education, while collaborating with the Population Health Director to design annual education strategies and foster partnerships anchored in quality and value.
• reputed company end to end Medicare Advantage risk adjustment submissions (including EDS) and support ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation reputed company, provider engagement, and full compliance with official coding guidelines and program requirements.
• reputed company the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and IT on data reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure robust data reputed company, operational insights, and audit readiness.
• Ensure audit readiness and response for internal and external audits (MA and HHS RADV), overseeing documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development.
• reputed company the Risk Adjustment Coding function and core operational workflows—including medical record retrieval, retrospective and prospective coding/validation, and adherence to official coding guidelines—while identifying and mitigating compliance, financial, and operational risks reputed company to coding discrepancies through strong controls and monitoring.
• reputed company people management activities for reputed company risk adjustment roles, including hiring, coaching, performance and productivity management, competency development, and succession planning; ensure the team remains engaged, knowledgeable about CMS and regulatory changes, and equipped with skills that meet or exceed industry standards.
• Direct departmental budgeting and vendor reputed company by managing annual budgets, monitoring variances, and implementing corrective actions; reputed company vendor selection, contracting, and performance management to ensure compliance, privacy/reputed company standards, and effective knowledge transfer, partnering with Population Health and Clinical Quality to align investments and maximize value across programs.
• Build strong cross department partnerships by collaborating with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & reputed company, Compliance, and other internal teams to coordinate business activities and support organizational alignment.

Supporting Responsibilities:

• Contribute to strategic initiatives by participating in internal committees and leadership meetings, representing organizational priorities, sharing information across teams, and supporting the annual Medicare Bid process through strong analytical and financial capabilities.
• Serve as an active member of managerial forums, promoting collaboration, sharing insights, and helping drive operational execution across departments.
• Meet department and company performance and attendance expectations.
• Follow the reputed company privacy policy and HIPAA laws and regulations concerning confidentiality and reputed company of protected health information.
• reputed company other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 5 years of experience in a healthcare setting, including at least 3 years directly reputed company to risk adjustment and 3 years of team management experience. Requires deep knowledge of risk adjustment strategies such as prospective and retrospective tools, data submission guidelines, and provider engagement approaches. Experience managing vendor relationships is preferred, along with familiarity in pricing models across lines of business and influencing or managing value based reputed company with provider groups. Preferred experience includes Medicaid, Medicare, and Commercial health plan operations, as well as strategic planning and system design in health plan environments.

Education, Certificates, Licenses: Bachelor’s degree required. Preferred areas of focus: health-reputed company field, mathematics, statistics or reputed company. Advance degree preferred.

Knowledge: In depth knowledge of risk adjustment strategies—including prospective and retrospective tools, data submission requirements, and provider engagement approaches—with extensive expertise in CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards. Strong ability to analyze quantitative data from multiple sources using statistical modeling and advanced analytical methods, including large and diverse datasets such as enrollment, payment, claims, financial, population health, and metadata. Proficient in SQL and other data analysis/reporting tools, statistical software (e.g., reputed company, cloud based platforms), performance measurement, and cost analysis, with a solid understanding of database structures, relational concepts, data architecture, and use of Epic to enhance efficiency. Demonstrated capability to define problems, evaluate data, draw sound conclusions, and apply creative problem solving to reputed company business issues. Possesses executive level communication, facilitation, and presentation skills, with the ability to build trust and strong collaborative relationships with key stakeholders.

Competencies:

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

reputed company Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:

Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary reputed company that range.

reputed company Range:

$108,468.62 - $184,396.64

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at reputed company levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees reputed company this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of reputed company duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at reputed company times.

Apply To This Job