Staff VP Commercial Risk Adjustment

Elevance Health•Atlanta, MN

8d•Hybrid

About The Position

The Staff VP Commercial Risk Adjustment is responsible for setting and executing the enterprise strategy for commercial risk adjustment across fully insured and self-funded lines of business. This role owns program performance, operating model design, regulatory and audit readiness, and cross-functional alignment to optimize risk score accuracy, documentation integrity, coding practices, and financial outcomes. The Staff VP partners closely with enterprise functions and leaders to deliver measurable improvements in risk adjustment results while maintaining best-in-class governance and ethical standards.

Requirements

Requires a BA/BS preferably in Business, Health Administration, Public Health, Finance, Data/Analytics and minimum of 10 years’ experience with healthcare economics and/or risk adjustment; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

10 years of progressive leadership experience in health plan and/or provider risk adjustment, payment integrity, coding, clinical documentation improvement, or related functions strongly preferred.
Deep knowledge of commercial risk adjustment methodologies and operations (e.g., diagnosis capture and coding workflows, documentation standards, submission processes) strongly preferred.
Proven track record of delivering measurable financial and operational outcomes in a regulated environment.
Demonstrated executive-level stakeholder management and the ability to influence across a matrixed environment.
Strong command of compliance and control environments, including audit readiness and governance practices.
Advanced analytical and problem-solving skills; ability to translate data into operational action and executive-ready narratives.
Experience implementing risk adjustment technology solutions (workflow platforms, NLP/AI augmentation, chart retrieval automation, analytics tools).
Familiarity with broader payment and quality programs (e.g., Stars/quality integration, medical economics, care management workflows).
Master’s degree (MBA, MHA, MPH) or equivalent advanced training.
Professional credentials such as CPC, CCS, CRC, RHIA/RHIT, RN (or similar), or significant experience leading credentialed coding/clinical teams.

Responsibilities

Define and lead the multi-year commercial risk adjustment strategy, roadmap, and annual operating plan.
Establish a scalable operating model (centralized, market-based, or hybrid) with clear accountability, governance, and performance management.
Build, mentor, and lead high-performing teams across risk adjustment operations, analytics, provider education, and program management.
Serve as the executive point of accountability for commercial risk adjustment performance, including reporting to senior leadership and relevant governance committees.
Own end-to-end performance across risk capture, coding accuracy, documentation improvement, and submission processes to maximize appropriate risk recognition.
Partner with Actuarial and Finance to quantify program impact, forecast performance, and manage variance to plan.
Drive prioritization of interventions (e.g., suspecting, chart review, provider engagement, clinical documentation improvement) based on ROI and risk.
Ensure consistent measurement frameworks and KPI dashboards (e.g., risk score trends, capture rates, HCC prevalence, coding accuracy, submission timeliness).
Lead provider-facing risk adjustment enablement strategy, including education, feedback loops, and workflow integration.
Partner with Network/Provider Relations to incorporate risk adjustment performance expectations into value-based contracts where appropriate.
Collaborate with EMR/EHR and vendor partners to improve clinical documentation workflows and reduce provider abrasion.
Oversee development of actionable insights for provider groups.
Sponsor analytics and technology capabilities to support risk adjustment (e.g., suspecting models, NLP, chart retrieval, workflow tools, submission automation).
Ensure strong data governance and data quality controls across clinical, claims, provider, and vendor data sources.
Partner with IT and Analytics to define requirements, prioritize builds, and ensure solutions are scalable, secure, and compliant.
Evaluate, select, and manage vendors supporting risk adjustment operations and analytics.
Establish and maintain policies, procedures, and controls that ensure compliant, ethical risk adjustment practices.
Ensure audit readiness and defensibility for all risk adjustment activities, including documentation standards, coding policies, and vendor oversight.
Partner with Compliance/Legal to interpret regulatory guidance and implement changes to policies and operations.
Oversee internal monitoring, risk assessments, corrective action plans, and ongoing education to minimize operational and regulatory risk.
Document key processes and operational controls for key areas, including chart acquisition, coding review, reconciliation, and submissions.
Implement continuous improvement using structured methodologies.
Develop strong change management and communication plans to support adoption across clinical and operational stakeholders.