Director, Risk Adjustment

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🔥 0 minutes ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

💵 $127.3k - $216.5k / year

⏰ Full Time

🔴 Lead

🎲 Risk

👻 Ghost score 20%

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PACIFICSOURCE

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

Not-for-profit health plans

📋 Description

• Establish and maintain the enterprise risk adjustment strategy, governance, and control framework • Define performance measures, operating cadence, roles and responsibilities, and resourcing for accurate, complete, and compliant data submission • Develop and implement scalable prospective engagement and education programs to improve documentation and diagnosis reporting • Support member engagement strategies aligned with improved health outcomes • Oversee provider feedback, Annual Wellness Visit insights, and Coding team education • Design annual education strategies with the Population Health Director • Oversee end-to-end Medicare Advantage risk adjustment submissions, including EDS • Support ACA EDGE Server activities • Lead risk adjustment analytics, including risk score and submission monitoring, reporting, and analytics • Partner with Actuarial, Finance, and IT on reconciliation, forecasting, scenario modeling, regulatory impacts, and payment methodologies • Ensure audit readiness and response for MA and HHS RADV audits • Oversee documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development • Lead risk adjustment coding and operational workflows, including medical record retrieval, retrospective and prospective coding/validation, and coding guideline adherence • Lead hiring, coaching, performance management, competency development, and succession planning • Direct departmental budgeting and vendor oversight, including vendor selection, contracting, and performance management • Build partnerships with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other internal teams • Participate in internal committees and leadership meetings • Support the annual Medicare Bid process • Serve as an active member of managerial forums • Meet department and company performance and attendance expectations • Follow PacificSource privacy policy and HIPAA laws and regulations • Perform other duties as assigned • Report to the Vice President of Quality and Population Health

🎯 Requirements

• Minimum of 5 years of experience in a healthcare setting • At least 3 years directly related to risk adjustment • 3 years of team management experience • Deep knowledge of risk adjustment strategies, including prospective and retrospective tools, data submission guidelines, and provider engagement approaches • Experience managing vendor relationships preferred • Familiarity with pricing models across lines of business and influencing or managing value based contracts with provider groups • Preferred experience with Medicaid, Medicare, and Commercial health plan operations • Strategic planning and system design experience in health plan environments preferred • Bachelor’s degree required • Advanced degree preferred • In-depth knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards • Ability to analyze quantitative data from multiple sources using statistical modeling and advanced analytical methods • Proficiency in SQL and other data analysis/reporting tools • Proficiency in statistical software, such as SAS and cloud-based platforms • Knowledge of performance measurement, cost analysis, database structures, relational concepts, and data architecture • Experience using Epic to enhance efficiency • Ability to define problems, evaluate data, draw sound conclusions, and apply creative problem solving to complex business issues • Executive-level communication, facilitation, and presentation skills • Ability to build trust and collaborative relationships with key stakeholders • Ability to read and comprehend written and spoken English • Ability to communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and lift/carry files and business materials • Must follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

🏖️ Benefits

• Equal opportunity employment • Work-from-home arrangement • Ergonomically configured equipment • Travel opportunities/required travel approximately 10% of the time