Director, Risk Adjustment

Job not on LinkedIn

🕒 October 22

🎸 Tennessee – Remote

🎸 Tennessee – Remote

💵 $127.3k - $216.5k / year

⏰ Full Time

🔴 Lead

🎲 Risk

👻 Ghost score 20%

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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 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

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