Risk Adjustment Director

Central California Alliance for Health•Mariposa County, California, CA

5d•Hybrid

About The Position

This position can be located in one of our service counties (Mariposa, Merced, Monterey, Santa Cruz, or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire. The Alliance is seeking a Risk Adjustment Director to lead the Risk Adjustment Department. This role involves providing strategic management oversight in designing, implementing, directing, and monitoring the department's functions. The Director will act as a subject matter expert, offering executive-level advice on coding, risk adjustment methodologies, and business operations, and will manage and supervise department staff.

Requirements

Knowledge of the managed care industry and of Medicare health insurance payment methodologies
Knowledge of Medicare (Hierarchical Condition Categories) risk adjustment models
Knowledge of methods and techniques of developing and delivering data management strategies that support contract analysis, trend management, budgeting, forecasting, strategic planning, and healthcare operations
Knowledge of principles and practices of provider reimbursement methodologies, pricing, and fee schedules for all provider types, including hospital, physician, and ancillary providers
Knowledge of healthcare industry specific terms and healthcare related data types and structures, including member, claims, clinical, and provider types
Knowledge of methods and techniques of valuating for physician and inpatient and outpatient hospital costs
Demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk
Perform complex analysis related to rate negotiations, health care cost reports, and determination of rates for hospitals, clinics, long-term care facilities, allied health services, professional services, and specialist services
Develop, plan, organize, and direct finance programs and activities that are complex in nature and regional in scope
Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
Demonstrate a collaborative management style, build rapport, demonstrate excellent public relations skills, and effectively manage internal and external business relationships
Bachelor’s degree in Finance, Business, Healthcare Administration, Mathematics, Statistics, or a closely related field
A minimum of ten years of experience in healthcare finance or analytics, which included a minimum of five years of experience with Medicare risk adjustment processes, a minimum of two years of experience related to Medicare Managed Care Programs, and a minimum of three years of supervisory experience (a Master’s degree may substitute for two years of general healthcare finance or analytics experience); or an equivalent combination of education and experience may be qualifying
Must reside in California upon hire
Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.

Nice To Haves

Medi-Cal experience is a plus
IPA/Medical Group experience highly desired
Expertise in risk adjustments
Strength in building relationships and partnering with cross-functional teams
Champion accountability across the organization
Experience in overseeing the Medicare Risk Adjustment life cycle
Strong data and analytical skills, including SQL, dashboarding, and reporting
Invested in staff development and empowering teams to do their best work

Responsibilities

Provide strategic management oversight in designing, implementing, directing, and monitoring the Alliance’s Risk Adjustment Department functions
Direct the Risk Adjustment Department, act as a subject matter expert, and provide executive-level advice and guidance on coding and risk adjustment methodologies and overall business operations
Direct, manage, and supervise Risk Adjustment Department staff