Director, Risk Adjustment

PacificSource Health Plans

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All 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 origin, genetic information or age. PacificSource 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 develop 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 all 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, leverage analytics, and implement compliant optimization strategies. Key accountabilities include program design and management, vendor oversight, provider and member outreach when applicable, and leadership of business intelligence efforts supporting Medicare Advantage, ACA Commercial, and Medicaid risk adjustment performance.

Requirements

Minimum of 5 years of experience in a healthcare setting, including at least 3 years directly related 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.
Bachelor’s degree required.
Preferred areas of focus: health-related field, mathematics, statistics or related.
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., SAS, 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 complex business issues.
Possesses executive level communication, facilitation, and presentation skills, with the ability to build trust and strong collaborative relationships with key stakeholders.

Nice To Haves

Experience managing vendor relationships is preferred, along with familiarity in pricing models across lines of business and influencing or managing value based contracts 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.
Advance degree preferred.

Responsibilities

Establish and maintain the enterprise risk adjustment strategy, governance, and control framework—defining performance measures, operating cadence, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs.
Develop and implement scalable prospective programs engagement and education programs dedicated to driving continuous 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 aligned with improved health outcomes.
Oversee 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.
Oversee end to end Medicare Advantage risk adjustment submissions (including EDS) and support ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation integrity, provider engagement, and full compliance with official coding guidelines and program requirements.
Lead 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 lineage, 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.
Lead 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 related to coding discrepancies through strong controls and monitoring.
Lead people management activities for all 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 oversight by managing annual budgets, monitoring variances, and implementing corrective actions; lead vendor selection, contracting, and performance management to ensure compliance, privacy/security 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 & Underwriting, Compliance, and other internal teams to coordinate business activities and support organizational alignment.
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 PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.