Director, Prospective Risk Adjustment & Revenue Integrity

Inland Empire Health Plan; Rancho Cucamonga (CA); Hybrid; USD 154,000 - 204,000; Full time

Benefits offered by this job

Competitive salary

Fitness center on-site

Medical, Dental, Vision

Life, disability insurance

Professional development

Wellness programs

FSAs

CalPERS retirement

457(b) plan

Pet insurance

Job summary

IEHP is seeking a Director of Risk Adjustment Prospective Programs to lead proactive risk capture across the plan, including in-home, virtual, and point-of-care initiatives. This role directs KPI development, workflow design, and provider tools to enhance CMS compliance and revenue integrity.

The position reports to the Vice President of Risk Adjustment and operates in a hybrid setting in Rancho Cucamonga, CA, collaborating with independent clinics, IPAs, and analytics teams to optimize care

Qualifications

• Minimum eight years in healthcare managed care or risk adjustment operations.
• At least five years in leadership of teams, projects, initiatives, and cross-functional groups.
• CRC or CPC certification or CDI credential preferred; CA RN/NP license preferred

Responsibilities

• Design and execute prospective risk adjustment programs.
• Oversee in-home and virtual assessment campaigns for hard-to-reach members.
• Develop workflows to reduce provider burden and integrate with EHRs.
• Engage providers and align incentives for documentation quality.
• Coordinate with IPA Medical Directors and care management integration.
• Governance, reporting and continuous improvement for QA of prospective programs.

Skills

Leadership

Risk adjustment

Data analytics

Provider engagement

Project management

Education

Bachelor's degree

Master's degree preferred

RN/NP license preferred

Tools

Epic

Athena

eClinicalWorks

Job description

IEHP is seeking a Director of Risk Adjustment Prospective Programs to lead proactive risk capture across the plan, including in-home, virtual, and point-of-care initiatives. This role directs KPI development, workflow design, and provider tools to enhance CMS compliance and revenue integrity.

The position reports to the Vice President of Risk Adjustment and operates in a hybrid setting in Rancho Cucamonga, CA, collaborating with independent clinics, IPAs, and analytics teams to optimize care