Assistant Vice President (AVP), Risk Adjustment

Blue Cross and Blue Shield of North Carolina•Prior Lake, MN

4d•$210,268 - $336,430•Hybrid

About The Position

At Blue Cross NC, we’re making health care better for all – by listening deeply, challenging what’s possible, and putting care at the heart of everything we do. Join a purpose‑driven team where ideas spark change, growth is encouraged, collaboration fuels impact, and you’re supported with the flexibility and trust to do meaningful work. The Assistant Vice President (AVP) of Risk Adjustment provides strategic, operational, and financial leadership for all Risk Adjustment activities across Medicare Advantage and ACA Marketplace lines of business within a single-state health plan. This role is accountable for the design, execution, and continuous optimization of end‑to-end Risk Adjustment programs—ensuring accurate revenue capture, regulatory compliance, and sustainability of performance in a dynamic regulatory environment. Reporting to [SVP/VP, Finance / Risk / Population Health], the AVP serves as a key enterprise leader and strategic partner to Finance, Actuarial, Clinical, Network, Compliance, Analytics, and Operations teams. The role combines deep technical expertise with people leadership and enterprise influence.

Requirements

Bachelor’s degree required; Master’s degree (MBA, MPH, MHA, or similar) strongly preferred.
10+ years of progressive experience in Risk Adjustment within a health plan, with direct experience in: Medicare Advantage Risk Adjustment ACA Marketplace Risk Adjustment
5+ years of people leadership experience managing managers and/or senior leaders.
Deep knowledge of: CMS HCC and HHS Risk Adjustment models RADV audits and compliance requirements Coding guidelines (ICD‑10‑CM) and documentation standards
Proven ability to partner with executive leadership and influence enterprise-wide outcomes.
Strong analytical, financial, and communication skills.

Nice To Haves

Experience leading Risk Adjustment for both Medicare and ACA in the same organization.
Prior experience with single-state or regional health plans.
Demonstrated success navigating regulatory change and model transitions.
Experience integrating Risk Adjustment into value-based care or population health strategies.
Vendor management and RFP experience.

Responsibilities

Set and execute a multi-year Risk Adjustment strategy for Medicare Advantage and ACA Marketplace aligned to organizational growth, quality, and financial performance.
Anticipate and prepare for CMS and HHS regulatory changes, including RADV, V28, HCC model changes, audit trends, and policy updates.
Serve as the executive subject matter expert on Risk Adjustment performance, risk score accuracy, and revenue impacts.
Lead all Risk Adjustment functions, including: Provider documentation and coding strategy Provider education and engagement Retrospective and prospective chart review programs Data capture, submission, and reconciliation Audit readiness and response (RADV / HHS audits)
Ensure strong internal controls and processes supporting compliance, accuracy, and operational efficiency.
Oversee vendor strategy, performance management, and contract optimization.
Partner with Finance and Actuarial teams to forecast Risk Adjustment revenue, assess performance drivers, and quantify financial outcomes.
Monitor and report on risk score trends, coding completeness, coding accuracy, and return on investment (ROI).
Drive continuous improvement through data-driven insights, analytics, and performance dashboards.
Collaborate closely with Quality Management/STARS team, Medical Management, Population Health, and Clinical Informatics to integrate Risk Adjustment into care models and workflows.
Build and sustain strong relationships with provider groups, medical practices, and clinical leaders across the state.
Champion provider-friendly, compliant documentation strategies that support quality care and accurate risk capture.
Lead, mentor, and develop a high-performing Risk Adjustment team, fostering accountability, innovation, and continuous learning.
Establish clear goals, performance expectations, and succession planning.
Promote a culture of integrity, transparency, and cross-functional partnership.