AVP, Medicare Risk Adjustment Performance

Alignment Health • California Corporate Office, CA

3d • $198,219 - $297,329

About The Position

Alignment Health is seeking an Assistant Vice President, Medicare Risk Adjustment Performance to provide executive leadership for the company's Risk Adjustment performance strategy and operations. This role is crucial for achieving annual RAF performance objectives, driving provider and market execution, and ensuring Risk Adjustment activities align with the organization's financial, operational, and strategic goals. The AVP will lead the development and execution of enterprise-wide prospective, concurrent, and retrospective Risk Adjustment strategies, overseeing operational performance in areas such as provider engagement, coding operations, chart retrieval, submission, analytics, vendor management, and revenue realization. This position requires close collaboration with various departments including Market Operations, Network Management, Clinical Operations, Finance, Compliance, and Data & Technology to achieve enterprise Risk Adjustment goals, support audit readiness, improve provider performance, and foster long-term organizational growth.

Requirements

• Ten or more years of progressive experience in managed care, Medicare Advantage, healthcare analytics, healthcare finance, risk adjustment, population health or related operations.
• Experience leading enterprise Risk Adjustment programs across multiple markets and provider arrangements.
• Demonstrated responsibility for financial performance, forecasting, strategic planning, or major business initiatives.
• Proven track record managing executive stakeholders and enterprise-wide programs.
• Seven or more years of people leadership, including development of high-performing analytical or operational teams.
• Bachelor’s degree in healthcare, business, finance, analytics, information systems or a related field, or equivalent relevant experience.
• Demonstrated knowledge of CMS-HCC risk adjustment methodology, Medicare Advantage reimbursement, coding and documentation programs, encounter data, and performance measurement.
• Demonstrated experience designing or leading analytics, reporting, data governance or scalable data infrastructure that supports reporting accuracy, regulatory compliance and audit readiness.
• Experience leading complex cross-functional initiatives and working with executives, providers, vendors, compliance partners and technical teams.
• Experience with risk adjustment forecasting, provider performance analytics, data warehousing, SQL-based analytics or business intelligence platforms.
• Experience supporting multiple government-program lines of business or large, multi-market Medicare Advantage operations.
• Advanced ability to translate complex data into executive-level insights, recommendations and action plans.
• Strong verbal, written, presentation, organization and relationship-management skills.
• Must be efficient in Excel and preferred with SQL knowledge.
• Good organization skills
• Good analytical skills
• Good interpersonal skills
• Strong communication skills

Nice To Haves

• Advanced degree preferred.

Responsibilities

• Accountable for enterprise RAF performance outcomes and annual Risk Adjustment targets.
• Responsible for prospective, concurrent, and retrospective Risk Adjustment execution strategies.
• Provides executive oversight for chart retrieval, coding production, provider engagement, and coding submission performance.
• Establishes market and provider performance objectives and monitors achievement of operational results.
• Provides executive reporting and recommendations to senior leadership regarding Risk Adjustment performance, opportunities, risks, and resource needs.
• Oversees strategic vendor partnerships supporting enterprise Risk Adjustment capabilities.
• Lead the annual operating plan for Medicare risk adjustment performance, including goals, measures, milestones, resources and market-level execution plans.
• Provide leadership across prospective, concurrent and retrospective programs, including annual wellness visit support, suspecting and recapture initiatives, chart retrieval, coding production and submission readiness.
• Establish and monitor performance guidelines for quality, productivity, service levels and financial outcomes; ensure timely executive reporting and action-oriented performance reviews.
• Use risk adjustment analytics, reporting and strategic business analysis to identify opportunities, risks, root causes and interventions across markets, provider groups and programs.
• Accountable for partnership with Finance and Actuarial teams to forecast RAF performance, evaluate revenue implications, monitor financial outcomes, and improve forecast accuracy across markets and programs.
• Support bid development, revenue forecasting, and long-range planning activities.
• Evaluate financial impact of provider performance, coding initiatives, and operational investments.
• Provide executive visibility into Risk Adjustment financial performance and variances.
• Establish strategic direction and performance expectations for Risk Adjustment vendors and external partners.
• Oversee vendor contracts, service delivery, productivity, quality, compliance, and business outcomes.
• Ensure vendor capabilities align with enterprise Risk Adjustment strategy and future-state operating models.
• Serve as executive sponsor for provider coding performance and documentation improvement initiatives.
• Partner with Network Management, Market Operations and provider leadership to improve enterprise Risk Adjustment outcomes.
• Lead provider performance reviews, corrective action planning, and performance improvement initiatives across delegated and non-delegated arrangements.
• Establish accountability frameworks for IPA, provider and vendor performance.
• Develop scalable reporting, analytical and operational capabilities that improve organizational visibility, support audit readiness and reduce reliance on manual controls.
• Partner with DTS and enterprise analytics teams on Risk Adjustment data strategy and reporting capabilities.
• Define business requirements supporting workflow modernization, automation, provider enablement, and enterprise reporting.
• Sponsor technology initiatives that improve scalability, productivity, transparency, and audit readiness.
• Drive adoption of modern analytics capabilities supporting provider and market performance management.
• Ensure chart retrieval, coding production, provider engagement, and submission activities support enterprise RADV readiness objectives.
• Partner with the AVP, Risk Adjustment Integrity & Transformation on validation findings, reconciliation activities, diagnosis corrections, and audit remediation initiatives.
• Establish operational accountability for issues impacting diagnosis accuracy, documentation support, evidence availability, and revenue sustainability.
• Support development of the enterprise MRA business case and modernization initiatives supporting long-term Risk Adjustment performance and audit readiness.
• Establish policies, procedures, standard work and governance routines that support accurate and compliant execution across products and markets.
• Maintain knowledge of CMS risk adjustment requirements, model changes and regulatory guidance, and translate changes into operational plans, training and performance expectations.
• Communicate complex operational, technical and financial information as clear executive insights, decisions and business narratives.
• Build, mentor and retain a high-performing multidisciplinary team and foster cross-functional accountability and continuous improvement.
• Perform other duties as assigned.
• Develop multi-year Risk Adjustment performance strategies aligned with enterprise growth objectives.
• Establish annual goals, objectives, key performance indicators, and resource requirements.
• Lead business case development for Risk Adjustment investments, operational initiatives, and technology capabilities.
• Partner with executive leadership on future-state operating model decisions.
• Support enterprise budgeting, forecasting, and strategic planning processes.
• Oversees assigned leaders and staff. Responsibilities include workforce planning, recruiting, selecting, orienting and training employees; assigning work; setting goals; monitoring and appraising results; coaching and developing talent; and addressing performance in accordance with company policy.

Benefits

• Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive