Director, Risk Adjustment

Job not on LinkedIn

🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $127.3k - $216.5k / year

⏰ Full Time

🔴 Lead

🎲 Risk

👻 Ghost score 0%

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Establish and maintain enterprise risk adjustment strategy, governance, and control framework • Define performance measures, operating cadence, roles, responsibilities, and resourcing for compliant data submission • Develop 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 • Oversee Medicare Advantage risk adjustment submissions, including EDS, and support ACA EDGE Server activities • Lead risk adjustment analytics, including risk score and submission monitoring, reporting, analytics, forecasting, and scenario modeling • Ensure audit readiness and response for internal and external audits, including MA and HHS RADV • Lead risk adjustment coding operations, medical record retrieval, retrospective and prospective coding/validation, and compliance controls • Manage hiring, coaching, performance, productivity, competency development, and succession planning for risk adjustment roles • Direct departmental budgeting and 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 strategic initiatives, internal committees, leadership meetings, and the annual Medicare Bid process • Meet department and company performance and attendance expectations • Follow PacificSource privacy policy and HIPAA laws and regulations • Perform other duties as assigned

🎯 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 prospective and retrospective risk adjustment tools, data submission guidelines, and provider engagement approaches • Experience managing vendor relationships preferred • Familiarity with pricing models across lines of business and value-based contracts with provider groups • Preferred experience with Medicaid, Medicare, and Commercial health plan operations • Bachelor’s degree required • Advanced degree preferred • In-depth knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards • Strong quantitative data analysis, statistical modeling, and advanced analytical methods • Proficiency in SQL, data analysis/reporting tools, statistical software such as SAS, cloud-based platforms, performance measurement, and cost analysis • Understanding of database structures, relational concepts, data architecture, and Epic • Executive-level communication, facilitation, and presentation skills • 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

🏖️ Benefits

• Equal opportunity employment • Travel approximately 10% of the time • General office setting with ergonomically configured equipment