Director, Risk Adjustment Prospective Programs

Inland Empire Health Plans; Rancho Cucamonga (CA); On-site; USD 150,000 - 230,000; Full time

Benefits offered by this job

Competitive salary

On-site fitness center

Medical, dental, and vision insurance

Life, disability insurance

Career development

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) plan

Paid life insurance

Pet care insurance

Job summary

Inland Empire Health Plans (IEHP) seeks a Director of Risk Adjustment Prospective Programs to lead the design and execution of proactive risk adjustment initiatives across point-of-care, in-home, and concurrent settings. You will translate enterprise strategy into scalable workflows, KPIs, and provider-facing tools within a network of independent physicians and IPAs.

The role emphasizes CMS-compliant documentation, revenue accuracy, and collaboration with clinics, vendors, and internal

Qualifications

• Eight years of progressive experience in healthcare managed care or risk adjustment operations.
• Five years in leadership managing teams, projects, and cross-functional initiatives.
• CRC or CPC certification required; RN/NP license preferred in California.

Responsibilities

• Lead prospective risk adjustment programs across in-home, point-of-care, and concurrent activities.
• Develop scalable workflows, KPIs, and provider-facing tools for risk adjustment.
• Ensure CMS-compliant documentation and revenue accuracy in real time.
• Collaborate with independent physicians, IPAs, and vendors to drive adoption.

Skills

Strategic leadership

Risk adjustment

Program management

Change management

Stakeholder facilitation

Data literacy

Communication

Analytics tools

Vendor management

Cross-functional collaboration

Education

Bachelor's degree in nursing, public health, healthcare administration or related field

Master's degree in nursing, public health, healthcare administration or related field preferred

CRC or CPC certification

RN/NP license preferred

Tools

Epic

Athena

eClinicalWorks

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Vice President, Risk Adjustment, the Director of Risk Adjustment Prospective Programs is a strategic leader responsible for implementing, operationalizing, and optimizing the health plan's point-of-care, concurrent, and forward-looking risk adjustment initiatives. Unlike traditional retrospective 'chart chasing,' this role focuses entirely on prospective interventions, capturing accurate member health acuity before or during a provider encounter. This position executes the enterprise strategy and converts it into scalable workflows, controls, KPIs, EHR integrations, and provider-facing tools that reduce friction for independent clinicians and delegated IPAs.

The primary mandate of this position is to ensure the plan's risk adjustment program is a proactive, clinically driven model. Operating within a network structure comprised of independent, Fee-for-Service (FFS) practices and delegated Independent Physician Associations (IPAs), this Director leads programs such as in-home and virtual assessments, pre-visit suspecting, point-of-care documentation supports, and concurrent validation. This leader ensures chronic conditions are documented accurately to CMS compliance standards in real time, driving revenue accuracy and improving proactive clinical care management.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Education & Requirement

• A minimum of eight (8) years of progressive experience in healthcare managed care or risk adjustment operations, with a distinct, heavy emphasis on executing prospective (point-of-care, in-home, or concurrent) programs. At least five (5) years of leadership and management experience leading teams, projects, initiatives, and/or cross-functional groups. Demonstrated success improving compliant documentation capture, provider adoption, and submission integrity through EHR integrations and analytics driven suspecting
• Bachelor’s degree in nursing, public health, healthcare administration or a related field from an accredited institution required
  • Master’s degree in nursing, public health, healthcare administration or a related field from an accredited institution preferred
• Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC) from AAPC or AHIMA required
  • CDI certification (e.g., ACDIS CCDS) or comparable documentation improvement credential preferred
  • Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) or Nurse Practitioner (NP) license issued by the California BRN preferred

Key Qualifications

• Must have a valid California Driver’s license
• Comprehensive knowledge and in-depth understanding of:
  • Launching healthcare operations or behavioral change campaigns within a non-employed, independent FFS provider network
  • Prospective risk adjustment platforms, EHR alert integrations (Epic, Athena, eClinicalWorks, etc.)
  • Managing large-scale national prospective/IHA vendors (e.g., Signify, Matrix, Optum)
  • Program management, change management, and stakeholder facilitation for provider audiences. Vendor management (SLAs, ROI, data security) and budget stewardship
  • Prospective risk adjustment concepts and operations; documentation standards (ICD 10 CM/HCC, MEAT), HIPAA/privacy; RADV readiness principles
  • Encounter/EDPS submission mechanics and downstream data quality controls
• Exceptional communicator capable of convincing fiercely independent, time crunched FFS providers to adopt prospective tools into their daily workflows
• Data literacy (Excel/BI tools) to monitor KPIs and communicate insights clearly
• Ability to balance prospective/concurrent capture with compliance and audit readiness
• Intermediate–advanced skills in using analytics tools (e.g., Excel, BI tools)
• Strong presentation and facilitation skills for varied clinical audiences
• Advanced ability to:
  • Build immediate peer-to-peer credibility with network physicians
  • Model change leadership, clear communication, and cross‑functional collaboration
  • Maintain strong professional relationships with providers, internal stakeholders, and external partners
  • Act as a credible advocate for prospective documentation excellence, while ensuring alignment with company policies and strategies
  • Prioritize resources using network tiering
  • Drive measurable outcomes while maintaining strong provider relationships