VP, Risk Adjustment & Quality

HJ Staffing • Huntington Beach, CA

1d • Onsite

About The Position

We are seeking a VP, Risk Adjustment & Quality to take ownership of the strategic integration between revenue integrity and clinical outcomes. In this role, you will oversee the complete lifecycle of risk capture including prospective, concurrent, and retrospective workflows while ensuring our organization maintains high performance in CMS Star Ratings and HEDIS quality metrics.

Requirements

• Education: Master’s degree in Business (MBA), Health Administration (MHA), or a related clinical field.
• Experience: 10+ years of progressive leadership in managed care, with specialized expertise in Medicare Advantage and Value-Based Care frameworks.
• Technical Knowledge: Deep understanding of ICD-10 coding standards, HCC methodologies, and CMS quality reporting.

Nice To Haves

• Certifications (Preferred): CPHQ (Quality), CHCA (HEDIS Auditor), or a clinical license (RN).

Responsibilities

• Strategic Execution: Develop and execute enterprise-wide Medicare Advantage risk adjustment strategies aligned with CMS requirements.
• SME Leadership: Serve as the subject matter expert on CMS-HCC models, risk score forecasting, and regulatory shifts.
• Operations Oversight: Manage all risk adjustment activities, including provider coding initiatives, chart reviews, in-home assessments, and data submissions.
• Compliance & Audit: Ensure full compliance with CMS, RADV, and OIG guidance. Lead internal and external audit responses.
• Performance Excellence: Drive year-over-year risk score performance while maintaining strict audit readiness.
• Cross-Functional Collaboration: Partner with network management and clinical leadership to improve documentation (CDI) and physician engagement.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive