Director, Risk Adjustment

PacificSource Health Plans•WFH: TN, TN

2d•$127,338 - $216,475

About The Position

The Director of Risk Adjustment reports to the Vice President of Quality and Population Health and is responsible for accurate, complete, and compliant risk adjustment data reporting to CMS. The Director leads enterprise-wide risk adjustment programs across all lines of business to identify risk exposure and optimization opportunities, overseeing the Analytic Manager and Coding Manager and their cross-functional operating teams. These teams support analytics and reporting, medical record retrieval, retrospective and prospective coding operations, and provider engagement while following official guidelines and industry best practices. The Director partners with providers, vendors, clinical leaders, and internal departments to improve documentation and coding accuracy through measurable initiatives. The role leads program design and management, vendor oversight, applicable provider and member outreach, and business intelligence efforts supporting Medicare Advantage, ACA Commercial, and Medicaid risk adjustment performance. Responsibilities also include audit readiness, people management, budgeting, operational controls, analytics, and coordination across enterprise functions.

Requirements

At least 5 years of experience in a healthcare setting.
At least 3 years of experience directly related to risk adjustment.
At least 3 years of team management experience.
Deep knowledge of risk adjustment strategies, including prospective and retrospective tools, data submission guidelines, and provider engagement approaches.
Bachelor’s degree required.
Extensive knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards.
Ability to analyze quantitative data from multiple sources using statistical modeling and advanced analytical methods, including large and diverse datasets.
Proficiency in SQL and data analysis and reporting tools, statistical software such as SAS or cloud-based platforms, performance measurement, and cost analysis.
Understanding of database structures, relational concepts, data architecture, and use of Epic to improve efficiency.
Ability to define problems, evaluate data, draw sound conclusions, and apply creative problem-solving to complex business issues.
Executive-level communication, facilitation, and presentation skills, and ability to build trust and collaborative relationships with stakeholders.
Skills in accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning.
Ability to perform the stated physical requirements: stoop and bend; sit and/or stand for extended periods; perform repetitive typing, sorting, and filing; lift and carry files and business materials lightly; comprehend written and spoken English; and communicate clearly and effectively.

Nice To Haves

Experience managing vendor relationships.
Familiarity with pricing models across lines of business and influencing or managing value-based contracts with provider groups.
Experience with Medicaid, Medicare, and Commercial health plan operations.
Experience in strategic planning and system design in health plan environments.
A degree focus in a health-related field, mathematics, statistics, or a related area.
Advanced degree.

Responsibilities

Establish and maintain the enterprise risk adjustment strategy, governance, control framework, performance measures, operating cadence, roles, responsibilities, and resourcing.
Develop scalable prospective engagement and education programs that improve documentation and diagnosis reporting, with transparent feedback and measurable objectives in value-based care.
Support member engagement strategies and wraparound services aligned with improved health outcomes.
Oversee provider feedback, Annual Wellness Visit insights, and coding team education; collaborate with the Population Health Director on annual education strategies and quality- and value-focused partnerships.
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 compliance.
Lead risk adjustment analytics, including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and IT on reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure data lineage, operational insight, and audit readiness.
Ensure readiness for and response to internal and external audits, including MA and HHS RADV; oversee documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development.
Lead risk adjustment coding and operational workflows, including medical record retrieval, retrospective and prospective coding and validation, and adherence to official coding guidelines; identify and mitigate related compliance, financial, and operational risks.
Manage risk adjustment personnel, including hiring, coaching, performance and productivity management, competency development, and succession planning; keep the team engaged, informed about regulatory changes, and equipped to meet industry standards.
Manage departmental budgets and vendor oversight, including budget monitoring and corrective actions, vendor selection, contracting, and performance management; ensure compliance and privacy/security standards, effective knowledge transfer, and alignment of investments across programs.
Build cross-department partnerships with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial and Underwriting, Compliance, and other teams.
Participate in internal committees and leadership meetings, represent organizational priorities, share information across teams, and support the annual Medicare Bid process.
Participate in managerial forums, promote collaboration, share insights, and support operational execution across departments.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policy and HIPAA requirements concerning confidentiality and security of protected health information.
Perform other duties as assigned.