Director, Risk Adjustment

Job not on LinkedIn

🔥 3 minutes ago

🎸 Tennessee – Remote

🎸 Tennessee – 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

• Report to the Vice President of Quality and Population Health • 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 and wraparound services 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, and scenario modeling • Ensure audit readiness and responses 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 workflows, 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 across Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other teams • Participate in strategic initiatives, internal committees, leadership meetings, and the annual Medicare Bid process • Meet department and company performance and attendance expectations • Follow privacy policy and HIPAA confidentiality and security requirements • 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 preferred • 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 • Strong quantitative data analysis, statistical modeling, and advanced analytical methods • Proficiency in SQL, data analysis/reporting tools, statistical software such as SAS, and cloud-based platforms • Knowledge of database structures, relational concepts, and data architecture • Experience using 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 light lifting/carrying

🏖️ Benefits

• Equal opportunity employment • Work inside in a general office setting with ergonomically configured equipment • Travel required approximately 10% of the time • Participation in internal committees and leadership meetings • Managerial forums and leadership development opportunities