SVP, Quality, Risk Adjustment, & Documentation

Wellbe Senior Medical•Remote,

6d•$250,000 - $330,000•Remote

About The Position

The SVP of Quality, Risk Adjustment & Documentation is a senior enterprise leader accountable for integrating and transforming three deeply interdependent functions: clinical quality performance, risk adjustment (RAF), and clinical documentation integrity. This role is revenue-critical; quality scores and RAF scores are the primary drivers of payer performance and financial sustainability in WellBe’s value-based care model. This is a fix-and-transform mandate. The SVP will be expected to stabilize underperforming operations, establish clear accountability structures, eliminate fragmentation, and build a unified, high-performing function that drives measurable outcomes. The successful leader will bring both strategic vision and hands-on execution capability, with a demonstrated record of improving payer performance in complex, fast-scaling healthcare environments.

Requirements

12+ years of progressive leadership experience in healthcare quality, risk adjustment, clinical documentation, or related functions within value-based care environments.
7+ years in a senior leadership role overseeing teams across coding, billing, quality, or risk adjustment.
Demonstrated success improving payer quality scores (STARS, HEDIS) and RAF performance at an enterprise or multi-market level.
Proven ability to consolidate fragmented functions and lead cross-functional transformation and operational change.
Experience managing payer audits (CMS RADV, OIG) and developing risk mitigation strategies.
Experience working with Medicare Advantage plans, ACOs, or other risk-bearing entities.
Deep expertise in Medicare Risk Adjustment (MRA), RAF score optimization, HCC coding, STARS, HEDIS, and related quality programs.
Strong understanding of clinical documentation improvement (CDI) principles and their connection to revenue and compliance outcomes.
Proficiency with data analytics tools (SAS, Tableau, SQL, or proprietary risk adjustment platforms); experience with AI-driven coding tools and EHR optimization preferred.
Strong financial acumen, with the ability to forecast revenue, identify performance trends, and optimize risk-adjusted performance.
Proven ability to engage and influence physicians and clinical teams, including training and performance improvement strategies.
Demonstrated experience building processes, controls, and performance-driven accountability cultures.
Bachelor’s degree from an accredited four-year college or university required.
Applicants must be legally authorized to work in the United States without the need for employer sponsorship now or in the future.
As a condition of employment, WellBe Senior Medical requires all candidates to successfully complete a pre-employment drug screening.
Employment is contingent upon successful completion of a background check, as permitted by law.

Nice To Haves

graduate degree (MBA, MHA, MPH, or clinical) preferred.
Current certification as a medical coder (CPC, CRC, or equivalent) preferred but not required.

Responsibilities

Lead enterprise strategy and execution for clinical quality outcomes, including performance against payer-driven metrics such as STARS and HEDIS.
Establish governance, reporting, and accountability structures to drive measurable, sustained improvement across all quality programs.
Partner with medical and clinical leadership to close care gaps, align documentation practices with quality performance goals, and drive outcomes across markets.
Serve as the enterprise authority on quality program strategy, ensuring alignment between clinical operations and payer performance expectations.
Own end-to-end risk adjustment strategy, execution, and performance, including HCC coding accuracy, RAF score optimization, and revenue integrity.
Partner with actuarial and finance teams to develop data-driven risk adjustment projections and revenue forecasts aligned to enterprise financial goals.
Engage Medicare Advantage payers to align on coding strategies, compliance requirements, and contract performance.
Identify and remediate gaps in RAF score captures, coding accuracy, and workflow execution; implement controls to reduce compliance risk and financial exposure.
Lead and manage all risk adjustment-related audits, including CMS RADV, OIG reviews, and payer audits, ensuring robust risk mitigation and audit readiness.
Oversee third-party risk adjustment vendors, ensuring compliance, contract optimization, and performance alignment.
Lead onboarding and integration of new health plan partners, supporting market expansion with scalable risk adjustment infrastructure.
Oversee the clinical documentation improvement (CDI) program, ensuring documentation accuracy, completeness, and alignment with regulatory and payer requirements.
Partner with clinical, compliance, and operations teams to standardize and continuously improve documentation practices across all markets.
Align documentation workflows with quality performance and risk capture goals, reducing gaps between clinical care delivery and coded outcomes.
Implement data validation and quality assurance processes to enhance coding accuracy and protect revenue cycle integrity.
Develop and implement physician and clinician education programs on coding best practices, CDI, and performance incentives.
Conduct targeted training for providers with identified coding or documentation gaps, ensuring alignment with risk adjustment accuracy goals.
Build strong partnerships with medical leadership to embed quality, documentation, and risk capture into clinical workflows and culture.
Consolidate quality, risk adjustment, and documentation functions under a unified operating model, eliminating silos and ensuring coordinated execution.
Design and implement an integrated governance and accountability structure across all three functions.
Drive adoption of digitally enabled workflows, AI-assisted coding tools, EHR optimizations, and predictive analytics to enhance operational scalability and efficiency.
Develop real-time performance dashboards and KPIs to monitor coding accuracy, quality scores, RAF performance, and revenue integrity at the market level.
Ensure full compliance with CMS, HHS, and all applicable regulatory guidelines across risk adjustment, billing, coding, and quality functions.
Proactively identify and manage operational, financial, and regulatory risks tied to quality and risk adjustment activities.
Partner with Compliance and Legal to ensure defensible practices, audit-ready documentation, and alignment with Medicare Advantage regulations.
Manage claim submissions; analyze rejections and develop corrective action plans.
Establish KPIs and reporting frameworks tied to quality scores, RAF performance, documentation accuracy, and financial outcomes.
Drive enterprise-wide accountability for results, with clear line-of-sight from team execution to payer and revenue performance.
Present performance insights and strategic recommendations to executive leadership and payer partners.