Director, Risk Adjustment & Analytics

PacificSource Health Plans; United States; Remote; USD 127,000 - 216,000; Full time

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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).

Skills

Leadership

Business acumen

Communication

Strategic planning

Situational leadership

Influence

Education

Bachelor's degree

Advanced degree preferred

Tools

SQL

SAS

Cloud platforms

Job description

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.