Vice President, Enterprise Risk Adjustment

Centene

About The Position

Centene is transforming the health of our communities one person at a time. As an Executive on our team, you could be the one who changes everything for our 28 million members. Position Purpose: A strategic and operational leader responsible for overseeing enterprise-wide risk adjustment policies, processes, and initiatives across all markets and lines of business. This executive will drive the development, implementation, and continuous improvement of prospective and retrospective strategies to ensure accurate and compliant provider data submissions. The role requires a blend of visionary leadership, operational excellence, and deep expertise in risk adjustment regulatory requirements. Lead day-to-day operational efforts across all markets to ensure timely and accurate capture and submission of risk adjustment related data. Develop and execute enterprise-wide risk adjustment strategies to align with regulatory requirements and financial objectives. Align risk adjustment strategies with enterprise goals, ensuring consistency while allowing for market-specific customization. Serve as the executive sponsor for cross-functional initiatives impacting risk adjustment. Drive the adoption of enterprise-wide best practices, tools, and methodologies. Develop and implement standardized processes while enabling tailored approaches for unique market or product needs. Promote a culture of accountability, innovation and compliance. Foster a culture of operational excellence through Lean, Six Sigma, or similar methodologies. Identify and eliminate inefficiencies, redundancies, and compliance risks in existing workflows. Champion innovation and data-driven decision-making to enhance program outcomes. Collaborate with Chief Health Officer on provider education needs to ensure documentation and coding accuracy. Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities. Oversee all risk adjustment-related compliance activities, including CMS RADV audits and internal/external reviews. Ensure timely and accurate submission of data in accordance with federal and state regulations. Monitor and ensure compliance with CMS, health plans, and state-specific regulations and audit requirements. Collaborate with Legal, Compliance, and Audit teams to mitigate risk and ensure audit readiness. Evaluate and optimize the vendor ecosystem to support scalability and innovation. Lead contract negotiations, performance management, and strategic alignment with all risk adjustment vendors. Establish KPIs and SLAs to ensure vendor accountability and value delivery. Translate complex risk adjustment data into actionable insights for executive leadership and the Board. Communicate risk exposure, financial impact, and progress toward strategic goals with clarity and precision. Serve as a thought leader and spokesperson for risk adjustment across the enterprise. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Bachelor's Degree in Business, Healthcare Administration, Public Health, or related field required.
10+ years of progressive leadership experience in risk adjustment, healthcare operations, or government programs required.
Deep understanding of CMS risk adjustment methodologies (HCC, CDPS, etc.), RADV audits, and regulatory frameworks.
Proven track record of leading large-scale, multi-market initiatives with measurable outcomes.
Strong vendor management and contract negotiation experience.
Exceptional communication, analytical, and leadership skills.
Expert level knowledge of CMS-HCC models for Medicare, Medicaid and Marketplace
Strong operational knowledge of coding standards (ICD-10, HCC) and clinical documentation expectations
Ability to influence and collaborate across matrixed organizations.
Executive presence with a strategic mindset and operational rigor.

Nice To Haves

Master's Degree preferred.
Lean Six Sigma certification or equivalent process improvement training preferred.
CPC certification preferred.
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.

Responsibilities

Lead day-to-day operational efforts across all markets to ensure timely and accurate capture and submission of risk adjustment related data.
Develop and execute enterprise-wide risk adjustment strategies to align with regulatory requirements and financial objectives.
Align risk adjustment strategies with enterprise goals, ensuring consistency while allowing for market-specific customization.
Serve as the executive sponsor for cross-functional initiatives impacting risk adjustment.
Drive the adoption of enterprise-wide best practices, tools, and methodologies.
Develop and implement standardized processes while enabling tailored approaches for unique market or product needs.
Promote a culture of accountability, innovation and compliance.
Foster a culture of operational excellence through Lean, Six Sigma, or similar methodologies.
Identify and eliminate inefficiencies, redundancies, and compliance risks in existing workflows.
Champion innovation and data-driven decision-making to enhance program outcomes.
Collaborate with Chief Health Officer on provider education needs to ensure documentation and coding accuracy.
Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities.
Oversee all risk adjustment-related compliance activities, including CMS RADV audits and internal/external reviews.
Ensure timely and accurate submission of data in accordance with federal and state regulations.
Monitor and ensure compliance with CMS, health plans, and state-specific regulations and audit requirements.
Collaborate with Legal, Compliance, and Audit teams to mitigate risk and ensure audit readiness.
Evaluate and optimize the vendor ecosystem to support scalability and innovation.
Lead contract negotiations, performance management, and strategic alignment with all risk adjustment vendors.
Establish KPIs and SLAs to ensure vendor accountability and value delivery.
Translate complex risk adjustment data into actionable insights for executive leadership and the Board.
Communicate risk exposure, financial impact, and progress toward strategic goals with clarity and precision.
Serve as a thought leader and spokesperson for risk adjustment across the enterprise.
Performs other duties as assigned.
Complies with all policies and standards.