VP, Risk Adjustment

Molina Healthcare•Long Beach, CA

About The Position

Provides executive level strategy and leadership for the operational integrity and regulatory compliance of the organization’s risk adjustment operations across all lines of business, including Medicare Advantage, Medicaid, and Affordable Care Act (ACA) Marketplace. Drives organizational risk adjustment policy, program standards, and performance, and maintains close partnerships with senior leaders across Clinical Operations, Analytics, Strategy, Technology, Encounters, Legal, and Compliance.

Requirements

At least 12 years of progressive experience in risk adjustment within a managed care or health plan environment, with direct accountability for program performance, or equivalent combination of relevant education and experience.
At least 7 years of management/leadership experience.
Demonstrated experience managing risk adjustment programs across multiple lines of business, including Medicare Advantage; Medicaid and Marketplace experience strongly preferred.
Comprehensive knowledge of Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment methodology, Medicaid risk adjustment frameworks, Marketplace risk adjustment program requirements, and Risk Adjustment Data Validation (RADV) audit processes.
Experience overseeing clinical data acquisition operations, chart review programs, and in-home or in-office assessment programs.
Proven ability to lead multi-vendor ecosystems and cross-functional programs in a complex, matrixed organizational environment.
Strong analytical acumen with demonstrated capability to interpret risk adjustment performance data, identify trends, and drive data-informed decision making.
Proven ability to collaborate and drive/influence large-scale organizational change and initiatives with internal/external stakeholders, including providers.
Experience developing and enforcing risk adjustment policies, coding standards, and compliance frameworks.
Excellent communication and influencing skills; proven ability to engage and align senior stakeholders across clinical, operational, and administrative functions.
Microsoft Office suite and applicable software programs proficiency, and ability to learn new information systems and software programs.

Nice To Haves

Medicaid and Marketplace experience strongly preferred.

Responsibilities

Provides executive oversight of all risk adjustment programs across Medicare Advantage, Medicaid, and ACA Marketplace lines of business, ensuring alignment of operational activities with organizational objectives and regulatory requirements. Supporting programs across the enterprise including interaction at the state plan level.
Leads end-to-end program management for chart review initiatives, in-home assessments (IHA), provider clinical programs, and supplemental data efforts across all applicable lines of business.
Serves as the primary internal interface for the organization's IHA capability, coordinating between internal teams and external IHA vendors engaged for supplemental capacity.
Manages provider-facing clinical programs, including in-office assessments, ensuring program design and execution are consistent with documentation and coding standards.
Establishes, maintains, and enforces enterprise-wide coding standards and Clinical Documentation Improvement (CDI) protocols applicable across all lines of business.
Oversees coding quality evaluation processes, ensuring accuracy, consistency, and compliance with Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Category (HCC) methodology, Medicaid risk adjustment guidelines, and ACA Marketplace risk adjustment requirements as applicable.
Owns and governs the end-to-end data flow from coding vendor output through internal quality assurance review to encounter staging, maintaining clear accountability at each stage of the process.
Partners with the Encounters team to ensure the timely, accurate, and compliant submission of encounter records, including both additions and deletions, across all applicable lines of business.
Designs and maintains tracking and reporting mechanisms to confirm encounter disposition, identify submission gaps, and drive resolution of outstanding items.
Establishes escalation pathways and control processes to minimize encounter submission risk and ensure regulatory deadlines are met.
Leads the coordination of all Risk Adjustment Data Validation (RADV) activities, including internal audit preparation, response management to CMS audit requests, and analysis of audit findings.
Develops and implements strategies to improve RADV performance, reduce audit exposure, and strengthen documentation standards over time.
Produces and maintains comprehensive performance reporting across all risk adjustment program activities, including coding results, encounter submission rates, HCC documentation outcomes, and performance against budget expectations.
Coordinates with Analytics and Strategy teams to translate program data into actionable insights, opportunity identification, and prioritized improvement initiatives.
Supports the organization's strategic planning processes with risk adjustment performance data, forecasting inputs, and program recommendations.
Ensures all programs operate in full compliance with CMS regulations, state Medicaid risk adjustment guidance, and ACA Marketplace risk adjustment rules.
Interfaces proactively with the internal Compliance function to surface program risks, policy gaps, and emerging regulatory changes requiring operational response.
Leads cross-functional policy development efforts and serve as the authoritative internal voice on risk adjustment regulatory requirements and standards.
Owns the full vendor management lifecycle for all risk adjustment vendors, including IHA overflow providers, coding vendors, and chart retrieval partners.
Establishes vendor service level agreements, performance scorecards, and governance structures to ensure quality, accountability, and value delivery.
Conducts regular vendor performance reviews and drives continuous improvement through structured feedback, remediation planning, and, where appropriate, contract renegotiation or vendor transition.
Leads re-engineering efforts for key workflows including clinical data acquisition, chart retrieval, coding quality review, and encounter submission pipelines.
Applies structured operational improvement methodologies to eliminate process gaps, reduce rework, and improve program outcomes across lines of business.
Develops and sustains a high-performance team, dedicated to best-in-class solutions; responsible for attracting, developing, and retaining top-tier talent to support strategy and long-term business objectives.