Director, Risk Adjustment Operations

Devoted Health • Waltham, MA

3d • $144,000 - $240,000 • Remote

About The Position

This role is fully remote and must be located within the 50 U.S. states. Preference for residence in the Greater Boston Area. Standard working hours are in Eastern Timezone. Semi-annual travel may be required to a Devoted office for on-site work. We are seeking a strategic and high-impact leader to serve as the Director of Risk Adjustment Operations. This pivotal role owns the end-to-end operational success of two core pillars within Devoted’s Risk Adjustment Department: Data Submissions and the Retrospective Chart Review Program. This role will lead the teams responsible for the successful submission of Devoted’s disease burden reporting by optimizing our internally developed Centers for Medicare & Medicaid Services (CMS) data submission engine while managing a high volume, multi-vendor retrospective medical document review operation. The objective is to achieve 100% complete and accurate acceptance of risk adjustment data through robust metrics, scalable workflows, and expert vendor management. You will directly engage with AI-enabled tools to optimize our processes.

Requirements

• Proven operator with a track record of transforming complex operational challenges into scalable, practical, and elegant business processes
• Systematic and detail-oriented approach to leadership, with a fierce commitment to quality, accuracy, and operational excellence
• Deeply analytical and research-oriented, with the ability to digest intricate regulatory or technical guidance and seamlessly incorporate it into daily operations
• Ability to manage and lead through ambiguity
• Can-do attitude and stamina for tackling hard problems
• High level of self-motivation and an ability to balance multiple priorities across initiatives
• Results-oriented: you are energized by having an ambitious goal and the latitude to execute against it
• Natural relationship builder and able to work well in a cross functional team environment

Nice To Haves

• Experience managing multiple teams and vendors
• Fast learner, can pick up new content/industries quickly in an extremely fast-paced tech environment
• Proven organizational, communication, and leadership skills
• Prior experience in Medicare Advantage risk adjustment, in particular RAPS and EDPS data submission and retrospective chart reviews preferred but not required

Responsibilities

• Develop, implement, and achieve KPIs that measure and monitor the successful submission of our risk adjustment data
• Manage relationship with Devoted’s data submission pass-through vendor, and CSCC Operations, CMS’ data submission team
• Read and make determinations on how new and emerging CMS technical guidance impacts our data submission operations
• Maintain our data submission policies, including our policy on how we internally validate, clean, and apply inclusion and exclusion criteria to the data we submit to CMS
• Support other areas of the Risk Adjustment department to ensure end-to-end perspectives are considered for all policy and procedure decisions
• Lead the strategic execution of the multi-channel Retrospective Chart Review Program, including defining, monitoring, and enforcing rigorous Service Level Agreements (SLAs) and Key Performance Indicators (KPIs) for internal teams, offshore partners, and external vendors
• Oversee medical record retrieval in partnership with the Clinical Data Acquisition team
• Own and improve program forecasts and capacity modeling
• Evaluate and integrate AI technologies to optimize the end-to-end chart review workflow, from medical record retrieval through evaluation
• Support QA and audit processes to achieve or exceed 95% coding accuracy

Benefits

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed