Director, Risk Adjustment
About The Position
PacificSource is seeking a Director of Risk Adjustment to join their team. This role is responsible for ensuring accurate, complete, and compliant Risk Adjustment data reporting to CMS and for leading enterprise-wide risk adjustment programs. The Director will oversee an Analytic Manager and Coding Manager, leading cross-functional teams focused on analytics, reporting, medical record retrieval, coding operations, and provider engagement. This position collaborates closely with providers, vendors, and clinical leaders to improve documentation and coding accuracy, and partners with various internal departments to streamline processes and implement compliant optimization strategies. Key accountabilities include program design, vendor oversight, provider and member outreach, and leadership of business intelligence for Medicare Advantage, ACA Commercial, and Medicaid risk adjustment.
Requirements
- Minimum of 5 years of experience in a healthcare setting.
- At least 3 years directly related to risk adjustment.
- At least 3 years of team management experience.
- Deep knowledge of risk adjustment strategies such as prospective and retrospective tools, data submission guidelines, and provider engagement approaches.
- Bachelor’s degree required.
- 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.
- 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.
- Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning.
Nice To Haves
- Experience managing vendor relationships is preferred.
- 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.
- Preferred areas of focus for Bachelor's degree: health-related field, mathematics, statistics or related.
- Advance degree preferred.
Responsibilities
- Establish and maintain the enterprise risk adjustment strategy, governance, and control framework.
- Develop and implement scalable prospective programs engagement and education programs.
- Support member engagement strategies to strengthen engagement and wrap around services.
- Oversee risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education.
- Oversee end to end Medicare Advantage risk adjustment submissions and support ACA EDGE Server activities.
- Lead the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics.
- Ensure audit readiness and response for internal and external audits.
- Lead the Risk Adjustment Coding function and core operational workflows.
- Lead people management activities for all risk adjustment roles.
- Direct departmental budgeting and vendor oversight.
- Build strong cross department partnerships.
- Contribute to strategic initiatives by participating in internal committees and leadership meetings.
- Serve as an active member of managerial forums.
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations.
- Perform other duties as assigned.
Benefits
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Director
