Director of Risk Adjustment Operations & Strategy

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 141,000 - 261,000; Full time

Job summary

CareFirst BlueCross BlueShield is seeking a Risk Adjustment Business Operations Director to lead risk adjustment outcomes for Medicare Advantage, Medicaid, and ACA markets. The role drives strategic direction, establishes key functions, and oversees enterprise RADV programs across populations and products.

Collaboration with enterprise stakeholders is essential to improve accuracy and performance. The position requires extensive healthcare experience with risk adjustment, strong leadership, and

Qualifications

• Bachelor's degree in a health or analytics field, or equivalent experience.
• 8 years progressive healthcare experience, with 3 years in risk adjustment.
• Experience in Medicaid/Medicare/ACA/BHP environments.
• Coding certification (CPC/CRC/CPMA or CCS/CCS-P) preferred.

Responsibilities

• Define and establish standards for in-year Risk Adjustments, KPIs, OKRs, ROI and risks.
• Oversee enterprise risk adjustment processes and regulatory changes.
• Develop action plans for accurate RADV, encounter data and ACA EDGE submissions.
• Lead partnerships and mentor teams to drive cross-functional improvements.
• Guide executives and stakeholders on regulatory compliance and performance.

Skills

Leadership

Risk Adjustment

Data Analytics

Regulatory Knowledge

Strategic Planning

Education

Bachelor’s Degree

Job description

CareFirst BlueCross BlueShield is seeking a Risk Adjustment Business Operations Director to lead risk adjustment outcomes for Medicare Advantage, Medicaid, and ACA markets. The role drives strategic direction, establishes key functions, and oversees enterprise RADV programs across populations and products.

Collaboration with enterprise stakeholders is essential to improve accuracy and performance. The position requires extensive healthcare experience with risk adjustment, strong leadership, and