Director, Risk Adjustment

PacificSource Health Plans; United States; A distancia; USD 127.000 - 216.000; Jornada completa

Descripción de la vacante

PacificSource Health Plans seeks a Director of Risk Adjustment to lead enterprise risk adjustment programs across Medicare Advantage, ACA Commercial, and Medicaid. You will oversee analytics, coding operations, and provider engagement, ensuring data accuracy and regulatory compliance.

Ideal candidates have 5+ years in healthcare risk adjustment, strong leadership, and expertise in CMS guidelines, with the ability to drive process improvements and collaborate with Finance, IT, and Operations.

Formación

• Deep knowledge of risk adjustment strategies including prospective and retrospective tools.
• Knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies.
• Executive communication, facilitation, and presentation skills; stakeholder collaboration.

Responsabilidades

• Define enterprise risk adjustment strategy, governance, and control framework across programs.
• Develop scalable prospective programs for documentation and diagnosis reporting with measurable objectives.
• Oversee risk adjustment processes including provider feedback and coding education; collaborate on annual education strategies.
• Lead end-to-end Medicare Advantage risk adjustment submissions and ACA EDGE Server activities with compliance.
• Manage risk adjustment analytics, forecasting, data reconciliation, and tool adoption with cross-functional teams.
• Ensure audit readiness and respond to internal/external audits (MA, HHS RADV).

Conocimientos

Leadership

Business acumen

Communication

Strategic planning

Situational leadership

Influence

Educación

Bachelor's degree

Advanced degree preferred

Herramientas

SQL

SAS

Cloud platforms

Descripción del empleo

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Director of Risk Adjustment, reporting to the Vice President of Quality and Population Health, is responsible for ensuring accurate, complete, and compliant Risk Adjustment data reporting to CMS and for leading enterprise-wide risk adjustment programs across all lines of business to identify risk exposure and optimization opportunities. This role oversees an Analytic Manager and Coding Manager that are accountable for cross functional operating team model including analytics and reporting, medical record retrieval, retrospective and prospective coding operations, and provider engagement while ensuring adherence to official guidelines and industry best practices. They partner closely with providers, vendors, and clinical leaders to enhance documentation and coding accuracy through measurable improvement initiatives, and collaborate with Finance, IT, Operations, and Quality to streamline processes, leverage analytics, and implement compliant optimization strategies. Key accountabilities include program design and management, vendor oversight, provider and member outreach when applicable, and leadership of business intelligence efforts supporting Medicare Advantage, ACA Commercial, and Medicaid risk adjustment performance.

Essential Responsibilities:

• Establish and maintain the enterprise risk adjustment strategy, governance, and control framework—defining performance measures, operating cadence, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs.
• Develop and implement scalable prospective programs engagement and education programs dedicated to driving continuous quality improvement in documentation and diagnosis reporting, with transparent feedback loops and measurable objectives in value-based care
• Support member engagement strategies to strengthen engagement and wrap around services aligned with improved health outcomes.
• Oversee risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education, while collaborating with the Population Health Director to design annual education strategies and foster partnerships anchored in quality and value.
• Oversee end to end Medicare Advantage risk adjustment submissions (including EDS) and support ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation integrity, provider engagement, and full compliance with official coding guidelines and program requirements.
• Lead the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and IT on data reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure robust data lineage, operational insights, and audit readiness.
• Ensure audit readiness and response for internal and external audits (MA and HHS RADV), overseeing documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development.
• Lead the Risk Adjustment Coding function and core operational workflows—including medical record retrieval, retrospective and prospective coding/validation, and adherence to official coding guidelines—while identifying and mitigating compliance, financial, and operational risks related to coding discrepancies through strong controls and monitoring.
• Lead people management activities for all risk adjustment roles, including hiring, coaching, performance and productivity management, competency development, and succession planning; ensure the team remains engaged, knowledgeable about CMS and regulatory changes, and equipped with skills that meet or exceed industry standards.
• Direct departmental budgeting and vendor oversight by managing annual budgets, monitoring variances, and implementing corrective actions; lead vendor selection, contracting, and performance management to ensure compliance, privacy/security standards, and effective knowledge transfer, partnering with Population Health and Clinical Quality to align investments and maximize value across programs.
• Build strong cross department partnerships by collaborating with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other internal teams to coordinate business activities and support organizational alignment.

Supporting Responsibilities:

• Contribute to strategic initiatives by participating in internal committees and leadership meetings, representing organizational priorities, sharing information across teams, and supporting the annual Medicare Bid process through strong analytical and financial capabilities.
• Serve as an active member of managerial forums, promoting collaboration, sharing insights, and helping drive operational execution across departments.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 5 years of experience in a healthcare setting, including at least 3 years directly related to risk adjustment and 3 years of team management experience. Requires deep knowledge of risk adjustment strategies such as prospective and retrospective tools, data submission guidelines, and provider engagement approaches. Experience managing vendor relationships is preferred, along with familiarity in pricing models across lines of business and influencing or managing value based contracts with provider groups. Preferred experience includes Medicaid, Medicare, and Commercial health plan operations, as well as strategic planning and system design in health plan environments.

Education, Certificates, Licenses: Bachelor’s degree required. Preferred areas of focus: health-related field, mathematics, statistics or related. Advance degree preferred.

Knowledge: In depth knowledge of risk adjustment strategies—including prospective and retrospective tools, data submission requirements, and provider engagement approaches, with extensive expertise in CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards. Strong ability to analyze quantitative data from multiple sources using statistical modeling and advanced analytical methods, including large and diverse datasets such as enrollment, payment, claims, financial, population health, and metadata. Proficient in SQL and other data analysis/reporting tools, statistical software (e.g., SAS, cloud based platforms), performance measurement, and cost analysis, with a solid understanding of database structures, relational concepts, data architecture, and use of Epic to enhance efficiency. Demonstrated capability to define problems, evaluate data, draw sound conclusions, and apply creative problem solving to complex business issues. Possesses executive level communication, facilitation, and presentation skills, with the ability to build trust and strong collaborative relationships with key stakeholders.

Competencies:

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:

Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$127,338.01 - $216,474.62

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.