Medical Director - Risk Adjustment
About The Position
The Medical Director, Risk Adjustment - will serve as the clinical expert responsible for advancing CareMore Health’s risk adjustment strategy. This physician expert will guide providers in accurate and complete documentation of patient complexity and chronic conditions, ensuring compliance with CMS requirements while supporting enterprise revenue integrity. The role will focus on healthcare provider education, data-driven interventions, and cross-functional collaboration with coding, analytics, and operations teams to maximize risk score accuracy, reduce audit exposure, and align risk adjustment with clinical and business objectives.
Requirements
- MD or DO required, with active, unrestricted medical license.
- 8+ years of clinical practice experience, with at least 3–5 years in an expert-level role involving risk adjustment, clinical documentation improvement (CDI), or value-based care.
- Demonstrated success leading provider education and engagement programs to improve coding and documentation.
- Experience with Medicare Advantage and CMS risk adjustment methodology (HCC coding, RAF scoring, RADV audits).
- Strong clinical and regulatory expertise in risk adjustment models and documentation standards.
- Data-driven leader with proven ability to interpret coding and quality data and translate into actionable interventions.
- Excellent communication and presentation skills, with ability to engage diverse provider audiences.
- Effective collaborator and change agent, able to partner across clinical, operational, and business teams.
Nice To Haves
- Board certification in Internal Medicine, Family Medicine, or related specialty strongly preferred.
Responsibilities
- Clinical Risk Adjustment Leadership Provide physician leadership in CareMore’s risk adjustment strategy, ensuring accurate capture of patient complexity and chronic conditions.
- Partner with enterprise leaders to set goals and monitor performance outcomes tied to risk adjustment and revenue integrity.
- Provider Engagement & Education Design, develop, and deliver education programs for physicians, advanced practice providers, and clinical staff to improve documentation integrity and coding accuracy.
- Serve as a visible champion for prospective risk capture at the point of care.
- Act as a trusted advisor and subject matter expert for providers on HCC coding and documentation best practices.
- Data Analysis & Performance Improvement Review coding, documentation, and quality data to identify performance gaps at provider, clinic, and market levels.
- Lead targeted interventions to improve RAF accuracy, reduce audit risk, and strengthen compliance.
- Collaborate with analytics teams to develop dashboards and reporting tools that track progress.
- Cross-Functional Collaboration Partner closely with coding, compliance, analytics, and operations teams to integrate risk adjustment into broader CareMore and Mosaic Health initiatives.
- Ensure risk adjustment strategies support enterprise priorities in quality, value-based care, and financial performance.
- Compliance & Audit Readiness Ensure all risk adjustment practices adhere to CMS and OIG regulations, including RADV requirements.
- Maintain audit-ready documentation and support compliance teams in responding to regulatory inquiries.
- Proactively adapt strategies based on regulatory changes to protect revenue integrity and enterprise reputation.
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What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
Ph.D. or professional degree
