Director, Risk Adjustment Products

🕒 3 days ago

🇺🇸 United States – Remote

💵 $170k - $225k / year

⏰ Full Time

🔴 Lead

🎲 Risk

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

Healthcare Insurance • SaaS • Fintech

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• The Director, Risk Adjustment Products will lead the strategy, roadmap, and execution for the product portfolio focused on retrospective risk adjustment solutions. • Work closely with technical and operations teams, both internally and externally, to create innovative solutions that deliver measurable impact for our customers. • Define multi-year plans aligned to customer outcomes, regulatory drivers, and market trends in risk adjustment, care management, and provider enablement. • Identify and prioritize use cases that leverage AI/ML and real-time data signals to surface high-impact suspects and coding opportunities. • Drive innovation leveraging interoperability standards (FHIR, HL7, APIs) to enable seamless enablement with EHRs, care management platforms, and third-party integrations. • Balance innovation with compliance, audit defensibility, and clinical integrity across all product decisions. • Lead the end-to-end product lifecycle, including ideation, requirements gathering, development, launch, and post-launch optimization. • Work closely with Engineering and Data Science to build predictive models and real-time data pipelines that power suspecting and concurrent workflows. • Ensure products are clinically relevant, user-centric, and integrated into existing payer and provider workflows through interoperability integrations. • Set and track KPIs for each product line, such as suspect accuracy, provider engagement, risk score impact, and concurrent coding capture and correction rates. • Establish and track KPIs that measure both risk adjustment performance and interoperability success (data exchange rates, provider adoption). • Serve as a trusted partner and clinical product expert for internal stakeholders (Sales, Clinical, Operations, Client Success) and external clients (health plans, ACOs, risk bearing provider groups). • Lead customer discovery and feedback sessions to deeply understand provider workflows, documentation behaviors, and concurrent coding needs. • Present product strategy and roadmap updates to executive stakeholders and client advisory boards. • Partner with Legal, Compliance, and Policy teams to interpret and operationalize updates from CMS (e.g., Final Rules, model updates, guidance on medical record standards). • Implement and monitor processes that ensure defensibility of all outputs, documentation standards, and audit trails. • Design and embed audit readiness into product workflows, ensuring all activities are traceable, evidence-backed, and aligned with CMS documentation requirements. • Provide strategic recommendations and decision frameworks when trade-offs between revenue, compliance, and user experience arise. • Build, lead, and coach a team of Product Managers working across different facets within prospective and concurrent solutions. • Provide mentorship, performance management, and career development aligned with leadership principles and growth culture. • Establish best-in-class product practices and instill a culture of experimentation, feedback, and continuous learning. • Support resourcing and hiring plans as product needs evolve and grow.

🎯 Requirements

• Bachelor’s degree in business or technical field required; Master’s degree in business or technical field preferred. • 10+ years of Risk Adjustment product management experience required. • 5+ years leadership experience required. • Experience with Risk Adjustment Products, developing and executing risk adjustment strategies, managing the retrieval and interoperability roadmap, improving retrieval yield, and supporting commercial client growth • Experience building the product strategy from scratch, creating the roadmap and executing with the Technology and Operation stakeholders. • Understanding of risk adjustment methodologies, including HCCs, CRGs, and other risk adjustment models used by CMS and commercial health plans. • Understanding of Medical Record Review, digital channels and interoperability and experience in chart retrieval products or operations. • Experience with people management, mentorship and creating inclusive and diverse teams. • Working in AWS cloud environment and experience with AWS cloud services. • Awareness of Agile tools and methodologies. • Understanding of SQL, Core Java, Spring Boot, Web Services, XML, JSON, SQL, Middleware, and CI/CD pipeline philosophy. • Ability to maintain confidentiality. • Thrives in a dynamic, sometimes ambiguous environment and has a knack for quickly prioritizing needs and creating scalable processes and structure. • Comfortable in a fully remote environment that relies heavily on asynchronous written collaboration and communication.

🏖️ Benefits

• HealthEdge commits to building an environment and culture that supports the diverse representation of our teams. • We aspire to have an inclusive workplace. • We aspire to be a place where all employees have the opportunity to belong, make an impact and deliver excellent software and services to our customers.