Risk Adjustment Provider Performance Consultant
About The Position
The Risk Adjustment Provider Performance Consultant role is a strategic, high-impact individual contributor role responsible for designing and executing comprehensive provider engagement and improvement strategies. Reporting to the Senior Director of Risk Adjustment and Analytics, this role serves as a principal subject matter expert and consultative partner to provider networks, ensuring complete and accurate medical record documentation. Acting as the critical bridge between clinical documentation, data analytics, and network strategy, this role will cultivate collaborative partnerships with provider clinic managers, billing leads, and coding supervisors to drive hands-on, localized performance improvement initiatives. Without direct people management responsibilities, this leader will rely on cross-functional influence, advanced data insights, and deep regulatory expertise to integrate risk adjustment efforts into the organization's broader value-based care and quality objectives.
Requirements
- Bachelor's Degree in Healthcare Administration, Business, Nursing, Health Information Management, or related field.
- 7+ years of relevant experience in lieu of a Bachelor's Degree
- 7+ years of extensive experience in Medicare Advantage risk adjustment, provider network management, provider education, or clinical documentation improvement (CDI) within a health plan or large provider group.
- 5+ years of progressive experience in strategic program management, matrix leadership, or advanced provider engagement, with a proven track record of driving large-scale initiatives without direct authority.
- Exceptional communication and presentation skills, with the ability to influence, consult, and persuade clinical leaders, executive stakeholders, and cross-functional partners.
- Strong ability to independently interpret complex performance data, collaborate with analytics teams, and translate findings into targeted, strategic provider interventions.
- Deep understanding of value-based care models, provider contracting, and how risk adjustment intersects with HEDIS/Quality metrics.
- Mastery of ICD-10-CM guidelines, CMS HCC methodologies, and official medical record documentation standards.
- AAPC Certified Risk Coder (CRC) – Required
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS / CCS-P) – Required
Nice To Haves
- Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) – Strongly Preferred
- Active Clinical License (e.g., RN, BSN) – Desired
Responsibilities
- Direct and independently manage the overarching provider engagement strategy for risk adjustment. Define strategic objectives, core workflows, and key performance indicators (KPIs) for network-wide provider outreach and engagement.
- Serve as the principal escalation point and strategic consultant for key provider group leadership regarding risk adjustment performance, documentation practices, and coding compliance.
- Partner closely with the Data & Analytics team to interpret complex provider performance data. Utilize advanced analytics to independently identify high-value intervention opportunities, pinpoint documentation gaps, and segment provider networks for targeted outreach.
- Proactively identify and action specific coding and documentation opportunities across the provider network. Provide advanced, consultative coding support and tailored feedback on complex cases to clinical partners, ensuring accurate capture of patient acuity and strict adherence to the latest CMS HCC and HHS coding guidelines.
- Forge strategic alignment with Provider Contracting, Health and Medical Management, and Quality teams. Influence and guide cross-functional stakeholders to seamlessly integrate risk adjustment goals into broader value-based care contracts and incentive programs.
- Design and present executive-level dashboards tracking provider engagement metrics, the ROI of strategic interventions, coding accuracy improvements, and overall network performance against enterprise targets.
- Act as a principal subject matter expert on CMS and HHS legislative and regulatory changes. Translate federal policy shifts into strategic operational plans and proactive communications for both internal leadership and provider partners.
- End-to-end ownership of multi-year provider-facing risk adjustment initiatives, ensuring flawless execution, continuous monitoring, and alignment with enterprise financial and compliance objectives.
Benefits
- comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
