Director Risk Adjustment (Peak Health)
About The Position
The Director of Risk Adjustment leads Peak Health's enterprise risk adjustment strategy and operations across all applicable lines of business. The role provides strategic direction and operational oversight to optimize accurate, complete, and compliant capture and submission of member risk data while supporting regulatory requirements, financial performance, and quality outcomes. The Director partners with clinical, provider, quality, actuarial, encounters, finance, compliance, IT, and other business leaders to develop and execute an integrated risk adjustment strategy. The role is accountable for establishing effective processes, controls, analytics, and performance management capabilities across the entire risk adjustment lifecycle. The position requires a bachelor's degree in a related field, at least eight years of progressive relevant experience, and five years of leadership experience. A master's degree and experience leading risk adjustment programs across Medicare Advantage, Individual ACA, and/or Medicaid are preferred.
Requirements
- Bachelor's degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field.
- Eight years of progressive experience in healthcare risk adjustment, health plan operations, coding, clinical documentation, or a related discipline.
- Five years of leadership experience.
- Excellent communication, analytical, organizational, and executive leadership skills.
- Ability to manage multiple complex initiatives in a highly regulated and rapidly changing environment.
Nice To Haves
- Master’s degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field.
- Experience managing and leading risk adjustment programs in Medicare Advantage, Individual ACA, and/or Medicaid; experience across multiple lines of business is strongly preferred.
Responsibilities
- Develop and execute the enterprise risk adjustment strategy and governance framework across all applicable lines of business.
- Monitor regulatory changes and emerging risk adjustment methodologies, translating them into operational strategies and process improvements.
- Oversee programs supporting accurate diagnosis capture, medical record retrieval, chart review, coding, validation, and submission of risk adjustment data.
- Establish and maintain coding standards, policies, procedures, and quality requirements across all applicable lines of business.
- Oversee coding quality assurance, second-level reviews, audits, corrective action processes, coder productivity, key performance indicators, and compliance with applicable CMS, state, federal, and organizational requirements.
- Develop and deploy risk adjustment value-based programs with key providers.
- Develop and maintain an enterprise risk adjustment performance dashboard with key performance indicators covering impacts, coding accuracy, chart retrieval, documentation, submission, audit performance, and operational efficiency.
- Partner with actuarial and finance teams to quantify the impact of risk adjustment operations on risk scores and improve projection accuracy for bids, pricing, forecasting, and accruals.
- Provide executive leadership with regular reporting on performance, risks, opportunities, and recommended actions.
- Ensure organizational readiness for CMS Risk Adjustment Data Validation (RADV) audits and regulatory reviews.
- Oversee relationships with external vendors supporting chart retrieval, coding, analytics, and other risk adjustment functions.
- Lead, develop, and mentor risk adjustment leaders and teams, establishing clear objectives, performance expectations, and professional development plans.
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What This Job Offers
Job Type
Full-time
Career Level
Director
