Director, Risk Adjustment Prospective Programs

IEHP; Rancho Cucamonga (CA); Hybrid; USD 123,000 - 204,000; Full time

Benefits offered by this job

Competitive salary

State of the art fitness center on‑sit

Medical Insurance with Dental and Vis

Life, short‑term, and long‑term disabi

Career advancement opportunities and

Job summary

IEHP in Rancho Cucamonga, CA is seeking a Director of Risk Adjustment Prospective Programs to lead proactive risk adjustment initiatives across the plan. You will design and operationalize point-of-care, in-home, and concurrent programs, and translate strategy into scalable workflows and provider tools.

Reporting to the VP Risk Adjustment, you will drive CMS-compliant documentation, enhance data quality, and collaborate with independent networks to optimize revenue integrity and patient care.

Qualifications

• Minimum eight years in healthcare managed care or risk adjustment operations.
• Five+ years in leadership managing teams and cross-functional projects.
• Experience improving documentation capture and submission integrity via EHR integrations.

Responsibilities

• Lead prospective risk adjustment programs (point-of-care, in-home, concurrent).
• Operationalize workflows, controls, KPIs, and provider-facing tools.
• Ensure CMS-compliant documentation and real-time accuracy in risk adjustment.

Skills

Exceptional communicator

Data literacy

Excel/BI tools

Stakeholder facilitation

Cross-functional collaboration

Education

Bachelor’s degree in nursing / public health / healthcare administration

Master’s degree in nursing / public health / healthcare administration (preferred)

CRC or CPC certification (AAPC or AHIMA)

CDI certification preferred (e.g., CCDS)

RN or NP licensed in California 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

• 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

Start your journey towards a thriving future with IEHP and apply TODAY!

Pay Range

• $154,128.00 USD Annually - $204,214.40 USD Annually