Director of Quality and Risk Adjustment

Advanced Health•Coos Bay, OR

4d•Hybrid

About The Position

The Director of Quality and Risk Adjustment provides strategic leadership for the development, implementation, oversight, and continuous improvement of organizational quality, risk adjustment, population health, and performance improvement programs. This position is responsible for establishing quality and risk adjustment frameworks, monitoring organizational performance, ensuring compliance with regulatory and contractual requirements. The Director collaborates with leadership, providers, and cross-functional teams to improve member outcomes, support value-based care initiatives, enhance revenue integrity, and drive organizational performance through data-informed decision making.

Requirements

Bachelor's degree in Healthcare Administration, Public Health, Nursing, Business Administration, Health Information Management, or a related field required.
Minimum of five years of progressively responsible leadership experience in healthcare quality improvement, performance improvement, risk adjustment, managed care, value-based payment models, or related healthcare operations.
Three to five years’ experience in Medicaid risk adjustment and coding experience.
Minimum three years’ experience in a medical office, clinic or healthcare administration setting.
Track record of success providing training, education, and guidance to providers and clinical staff.
Experience leading, training, and managing a team.
Certified Professional Coder or Certified Risk Adjustment Coder, willing to obtain within the first year of hire.
Comprehensive knowledge of healthcare quality improvement, population health management, risk adjustment methodologies, value-based care, Medicaid managed care, and applicable federal and state regulatory requirements.
Demonstrated skill in leading quality and risk adjustment programs; analyzing healthcare data and performance metrics; implementing process improvement initiatives; managing provider engagement strategies; and driving organizational performance through evidence-based decision-making.
Ability to develop and execute strategic initiatives that improve quality outcomes, health equity, compliance, and financial performance; translate complex data into actionable recommendations; and effectively communicate results to executive leadership, providers, and other stakeholders.
Strong leadership and relationship-management abilities, including building high-performing teams, fostering cross-functional collaboration, managing competing priorities, and influencing organizational change in a complex healthcare environment.
Knowledge of clinical documentation improvement, medical coding and classification systems (ICD-10, CPT, HCPCS), HEDIS and other quality measurement frameworks, healthcare analytics, and reporting tools used to support quality and risk adjustment performance.
Knowledge of evidence-based practices and requirements to evaluate existing standards and implement new procedures.
Understanding of principles of health care of populations.
Critical attention to detail for accuracy and timeliness.
High degree of initiative, judgment, discretion, and decision-making.
Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health conditions to determine best outcomes for members.
Ability to report to work as scheduled, and willingness to work a flexible schedule when needed.
Proficient in Microsoft Office Suite and Windows Operating System (OS).
Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission.
Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse.
Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
Attention to detail and organization skills.
Ability to handle stress and sensitive situations effectively while projecting a professional attitude.
Ability to communicate professionally, both conversing and written.
Ability to work with diverse populations and interact with people of differing personalities and backgrounds.
Sensitive to economic considerations, human needs and aware of how one’s actions may affect others.
Ability to organize and work in a sensitive manner with people from other cultures.
Poised; maintains composure and sense of purpose.

Nice To Haves

Master’s degree in relevant field strongly preferred.
Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred.
Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics.
Understanding of basic concepts of managed care.
Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access.
Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices.
Excellent people skills and friendly demeanor.

Responsibilities

Develop and execute the organization's strategic vision for quality improvement, risk adjustment optimization, and performance improvement initiatives.
Provide leadership in the design, implementation, evaluation, and continuous improvement of organizational quality and risk adjustment programs.
Establish departmental goals, objectives, key performance indicators, and performance improvement strategies aligned with organizational priorities.
Serve as a strategic advisor to executive leadership regarding quality outcomes, risk adjustment performance, population health, healthcare transformation, value-based reimbursement and regulatory requirements.
Identify emerging trends, risks, opportunities, and best practices and develop proactive strategies to support organizational success.
Foster a culture of continuous quality improvement, innovation, accountability, and data-driven decision-making throughout the organization.
Collaborate with executive leadership, providers, vendors, community partners, and stakeholders to advance organizational quality and risk adjustment initiatives.
Provide oversight and direction of the Quality Management Improvement (QMI) Program, Transformation and Quality Strategy (TQS), Performance Improvement Projects (PIPs), and related quality initiatives.
Ensure the development, implementation, and monitoring of quality improvement strategies that support contractual obligations, regulatory requirements, organizational goals, and population health outcomes.
Direct the development and utilization of evaluation tools, performance metrics, dashboards, and reporting systems used to monitor organizational performance.
Lead efforts to improve quality performance measures, incentive metrics, healthcare outcomes, member experience, and provider performance.
Monitor organizational performance and implement corrective action plans when performance goals are not achieved.
Oversee the validation, analysis, interpretation, and reporting of quality and performance data.
Ensure compliance with all applicable federal, state, accreditation, contractual, and regulatory quality requirements.
Direct the preparation and submission of required quality reports, performance improvement reports, and contractual deliverables.
Provide leadership to quality-related committees, workgroups, and stakeholder partnerships.
Collaborate with clinical and operational leaders to identify opportunities for systems transformation and process improvement.
Monitor delegated vendor performance related to quality activities and implement corrective actions when necessary.
Oversee readiness activities associated with audits, regulatory reviews, accreditation activities, and external quality reviews.
Provide strategic oversight and direction for all organizational risk adjustment activities.
Develop and implement comprehensive risk adjustment strategies that support organizational performance, revenue optimization, regulatory compliance, and population health goals.
Monitor risk adjustment performance metrics, coding accuracy, documentation integrity, and program effectiveness.
Direct provider education, engagement, and incentive strategies that support accurate clinical documentation and coding practices.
Utilize analytics to identify trends, opportunities, and areas for improvement related to risk adjustment performance.
Oversee relationships and performance of risk adjustment vendors, consultants, and external partners.
Ensure implementation of auditing and monitoring activities to evaluate documentation quality, coding accuracy, and program compliance.
Collaborate with internal departments and external stakeholders to resolve issues affecting risk adjustment performance and compliance.
Develop, implement, and maintain policies, procedures, and workflows supporting risk adjustment activities.
Monitor changes in risk adjustment methodologies, payment models, and regulatory requirements and implement program modifications as needed.
Provide strategic oversight of quality performance, risk adjustment analytics, population health metrics, and organizational performance measurement activities.
Develop, monitor, and report key performance indicators, dashboards, scorecards, and other performance measurement tools to support organizational goals and data-driven decision-making.
Analyze quality, risk adjustment, utilization, financial, and population health data to identify trends, care gaps, coding opportunities, performance variances, and opportunities for improvement.
Direct the collection, interpretation, and communication of performance data and outcomes to executive leadership, providers, committees, and key stakeholders.
Collaborate with clinical, operational, and provider teams to develop and implement performance improvement strategies that enhance member outcomes, patient experience, provider performance, and operational effectiveness.
Monitor performance against contractual, regulatory, payer, and organizational benchmarks and develop corrective action plans when performance targets are not achieved.
Ensure the integrity, accuracy, and effective use of quality, risk adjustment, utilization, and population health data to support quality improvement, strategic planning, and organizational performance initiatives.
Participate in quality and organizational process improvement activities when requested.
Support and contribute to effective safety, quality, and risk adjustment efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities.
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner.
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization.
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations.
Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications.
Advance personal knowledge base by pursuing continuing education to enhance professional competence.
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards.
Represent organization at meetings and conferences as applicable.
Plan, orient and assign work to personnel that supports goals and objectives contained in the organization’s Strategic Plan and delivers outstanding team-based services.
Promote a culture of risk-management, team-based, values-based, high-performance, and continually improving practice that values learning and a commitment to quality.
Establish and monitor assigned staff performance, assign accountabilities, set objectives, and establish priorities.
Ensure the completion of annual Development Reviews for assigned staff and recommend merit wage adjustments as appropriate, per policy.
Assist in the recruitment, hiring, orientation, development, and evaluation of assigned staff to ensure Promote employee retention, productivity, and satisfaction through ongoing support, encouragement, empowerment, coaching and effective teamwork.
Ensure staff comply with approved organizational policy and procedure.
Knowledge of federal and state employment and labor laws.
Assist employees to read, interpret and apply policies and procedures.
Support and mobilize assigned staff to engage in their assigned work through implementation of team building, performance coaching and problem-solving strategies.
Ensure that staff is cross-trained to accomplish the goals and objectives of the organization.
Responsible to back-up assigned staff workloads when necessary.
Respond to the needs of direct and indirect staff with clear, open, and honest communication, mutual respect, and consistent follow through to generate trust and enhance personal effectiveness.
Recommend discharge of employees, when indicated, based on work performance and behaviors.
Demonstrated teaching ability and experience.