Director, Risk Adjustment

Gold Coast Health Plan; California; Remote; USD 157,000 - 263,000; Full time

Job summary

Gold Coast Health Plan in California is seeking a Director of Risk Adjustment to lead the strategy, design, and monitoring of risk adjustment efforts and improve quality coding with providers.

This role requires extensive CMS knowledge, leadership in a matrixed environment, and collaboration with Finance and Compliance to drive audit readiness and performance improvements.

Qualifications

• Bachelor's degree and professional coder certifications.
• 10–12+ years in related roles with 7+ years in management.
• Strong knowledge of CMS-HCC, HHS-HCC, and RADV processes.

Responsibilities

• Develop and execute a risk adjustment strategy aligned to organization goals and CMS requirements.
• Design, implement, monitor and refine solutions to improve quality coding with physicians and providers.
• Lead cross-functional teams to ensure compliant reporting of risk adjustment data per CMS guidance.
• Oversee risk adjustment initiatives and vendor performance, SLAs, and improvement activities.
• Collaborate with Finance to forecast risk adjustments and track impact on financial outcomes.
• Support RADV audit readiness activities, including chart validation and documentation reconciliation.

Skills

Leadership

Strategic Planning

Analytical Thinking

Communication Skills

Project Management

Collaboration

Attention to Detail

Education

Bachelor's degree in Health Information Management, Healthcare Administration, Public Health or related field

CPC

CRC

CCS

Tools

MS Office Suite

EMR/EHR experience

Job description

## Director, Risk AdjustmentApply: California-Remote: Full time: Posted 2 Days Ago: JR100164Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best.If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.About this role:**Reasonable Accommodations Statement**To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions. **\\*\\*This position is open to California residents only.\\*\\*** **ESSENTIAL FUNCTIONS****Job Function & Responsibilities**• Develop and execute a risk adjustment strategy aligned to organization goals, regulatory requirements, and performance targets.• Design, implement and monitor and refine solutions and strategies to effectively improve the capture of accurate and comprehensive Quality Coding.• Develop and implement innovative and effective strategies to work with physicians and other providers to achieve organizational objectives in Quality Coding.• Develop and maintain a Quality Coding work-plan and convene committees and workgroups to drive and oversee risk adjustment work.• Responsible for implementation and oversight of risk adjustment and quality coding related initiatives and projects.• Partner with internal teams and oversee external vendor partners to monitor program and vendor performance, facilitate oversight, SLAs and performance improvement activities as needed.• Lead cross-functional teams, internal and external, to ensure complete, accurate, timely and compliant reporting of risk adjustment data in accordance with Centers for Medicare and Medicaid Services (CMS) requirements.• Lead, develop and analyze key indicators and other performance data and reporting tools related to the risk adjustment operations and performance to inform leadership on progress of activities and quality coding programs.• Partner with internal stakeholders and/or external vendors in the definition, design, implementation, and maintenance of data files and data extracts to meet reporting needs and encounter validation.• Apply and maintain knowledge of applicable current and proposed laws, regulations, and CMS guidance applicable to risk adjustment specifically, and general knowledge of Medicare Advantage and ACA/Exchange based requirements.• Collaborate with Network Performance, Compliance and other teams to deliver provider and staff education to facilitate clinical documentation improvement and improve performance and outcomes.• Oversee medical record review and audit process to ensure adherence to CMS Risk Adjustment data submission requirements and documentation standards.• Support CMS RADV audit readiness activities, including chart validation reviews, mock audits, record retrieval efforts, documentation reconciliation, and regulatory submissions.• Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider and vendor performance data.• Partner closely with Finance to forecast risk adjustments and track impact of coding quality.• Potential travel for auditing purposes.• Other duties as assigned. **MINIMUM QUALIFICATIONS****Education:**• Bachelor’s degree in Health Information Management, Healthcare administration, Public Health or a related field (required).• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS) training• Knowledge of Industry standard ICD-10-CM and CPT coding principles.**Experience:**• 10–12+ progressively responsible, related experience, including 7+ years in management• 3–5 years of experience in medical coding, risk adjustment, HCC coding, coding audits, and provider education.• Strong knowledge of CMS-HCC, HHS-HCC, and RADV processes.• Experience in the development & management of healthcare-related programs, which includes leading projects from ideation through execution and working in a highly matrixed environment with both internal and external partners.• Strong knowledge of ICD-10-CM, CPT, HCPCS, and risk adjustment methodologies.• Strong knowledge of CMS rules and requirements of Medicare Advantage Health Plans.• Demonstrated ability to think strategically to ensure program success.• Excellent analytical skills, data management capabilities, and strong attention to detail. Ability to review data and provide measurable outcomes and trend measures to support and influence business decisions.• Exceptional analytical, problem solving, and critical and strategic thinking skills. Willingness to take an innovative, creative approach to solving problems and developing solutions.• Self-starter motivated by the opportunity to work in fast-paced environments and driven by measurable outcomes. Effective time management with flexibility and adaptability to change.• Strong organization, time management, and prioritization skills. Ability to manage multiple projects while adjusting to changing priorities and business needs.• Excellent verbal and written communication skills with the ability to present complex information in a simplified easy to understand manner• Hands-on experience navigating electronic medical record (EMR/EHR)• Prior experience in Medicare Advantage health plan or managed care setting• Technical aptitude to learn new data management and analysis tools or methodologies quickly.• Collaborative approach to work with and ability to partner with different business areas.• Proficiency with the Microsoft Office Suite. **KNOWLEDGE, SKILLS & ABILITIES** **Preferred Qualifications:**• Advanced degrees or certifications (e.g.,, CFA, MBA) are a plus.• Certificate/strong proficiency in data analysis tools (e.g., Excel) and financial modeling• Ability to prioritize and manage multiple tasks in a fast-paced environment• Experience with risk adjustment data submission platforms• Experience with healthcare claims data• Familiarity with Medi-Cal and Medicare Advantage financial models**Technology & Software Skills**: Advanced computer skills in MS Office products.**Certifications & Licenses**:• Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or Certified Coding Specialist (CCS)• A valid and current Driver's License, Auto Insurance, and professional licensure(s)**Competency Statements**• Leadership Skills – Ability to lead groups, facilitate informed decisions.• Management Skills - Ability to organize and direct oneself and effectively supervise others.• Decision Making - Ability to make critical decisions while following company procedures.• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.• Interpersonal - Ability to get along well with a variety of personalities and individuals.• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.• Relationship Building - Ability to effectively build relationships with customers and co-workers.• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.• Judgment - The ability to formulate a sound decision using the available information.• Business Acumen - Ability to grasp and understand business concepts and issues.• Presentation Skills - Ability to effectively present information publicly.• Communication, Oral - Ability to communicate effectively with others using the spoken word.• Communication, Written - Ability to communicate in writing clearly and concisely.• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems. **The estimated pay range for the position is:**$157,303.00 - $262,697.00