Risk Adjustment QA & Quality Improvement Specialist

CalOptima; Orange (CA); Hybrid; USD 68,000 - 109,000; Full time

Benefits offered by this job

CalPERS pension program

Generous PTO

Tuition Reimbursement

Professional development opportunities

Flexible scheduling

Job summary

CalOptima Health is seeking a Quality Improvement Specialist, Risk Adjustment for Covered California to advance risk adjustment programs and support QA/Audit processes. You will collaborate with multiple units, providers and stakeholders to ensure data accuracy and compliant reporting.

The role supports national health plan risk adjustment activities with partial telework; periodic on-site work in Orange, CA is required.

Qualifications

• Bachelor's degree in health care, health care data informatics or related field plus 2 years of risk adjustment or quality improvement experience.
• Experience with HHS-RADV or risk adjustment programs is preferred.
• Strong communication, organization and analytical skills.

Responsibilities

• Support ACA, Medicare Advantage and Medicaid risk adjustment data accuracy and compliance.
• Review documentation and HCC validation; provide audit support.
• Develop dashboards and run charts for CQI project metrics.
• Monitor HCC capture rate, reporting, and provider engagement.
• Coordinate with provider relations and health network for risk adjustment initiatives.
• Track budgets, ROIs and support annual wellness visits and quality initiatives.

Skills

Quality improvement

Risk adjustment

Data analysis

Communication

Project coordination

Education

Bachelor's degree in health care / health informatics

Job description

CalOptima Health is seeking a Quality Improvement Specialist, Risk Adjustment for Covered California to advance risk adjustment programs and support QA/Audit processes. You will collaborate with multiple units, providers and stakeholders to ensure data accuracy and compliant reporting.

The role supports national health plan risk adjustment activities with partial telework; periodic on-site work in Orange, CA is required.