Director, Risk Adjustment

Job not on LinkedIn

🔥 3 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🔴 Lead

🎲 Risk

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Develop and execute the enterprise risk adjustment strategy and governance framework across all applicable lines of business • Monitor regulatory changes and emerging risk adjustment methodologies, translating them into operational strategies and process improvements • Oversee programs supporting accurate diagnosis capture, medical record retrieval, chart review, coding, validation, and submission of risk adjustment data • Establish and maintain coding standards, policies, procedures, and quality requirements across all applicable lines of business • Oversee coding quality assurance, second-level reviews, audits, corrective action processes, coder productivity, key performance indicators, and compliance with applicable CMS, state, federal, and organizational requirements • Develop and deploy risk adjustment value-based programs with key providers • Develop and maintain an enterprise risk adjustment performance dashboard with key performance indicators covering impacts, coding accuracy, chart retrieval, documentation, submission, audit performance, and operational efficiency • Partner with actuarial and finance teams to quantify the impact of risk adjustment operations on risk scores and improve projection accuracy for bids, pricing, forecasting and accruals • Provide executive leadership with regular reporting on performance, risks, opportunities, and recommended actions • Ensure organizational readiness for CMS Risk Adjustment Data Validation (RADV) audits and regulatory reviews • Oversee relationships with external vendors supporting chart retrieval, coding, analytics, and other risk adjustment functions • Lead, develop, and mentor risk adjustment leaders and teams, establishing clear objectives, performance expectations, and professional development plans

🎯 Requirements

• Bachelor's degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field • Eight (8) years of progressive experience in healthcare risk adjustment, health plan operations, coding, clinical documentation, or a related discipline • Five (5) years of leadership experience • Excellent communication, analytical, organizational, and executive leadership skills • Ability to manage multiple complex initiatives in a highly regulated and rapidly changing environment • Specific experience managing and leading risk adjustment programs in Medicare Advantage, Individual ACA, and/or Medicaid preferred • Master’s degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field preferred

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume