Director, Prospective Risk Adjustment Operations

Blue Cross and Blue Shield of Louisiana

Baton Rouge, LA

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JOB DETAILS

SKILLS

Analysis Skills, Business Administration, Business Strategy, Category Management, Clinical Study Publications, Communication Skills, Cross-Functional, Documentation, Finance, Healthcare, Healthcare Administration, Healthcare Providers, Healthcare Reimbursement, Home Care, Insurance, Law Enforcement, Leadership, Medical Coding, Medicare, Metrics, Nursing, Operational Audit, Operational Improvement, Operational Strategy, Operations Planning, Organizational Skills, Performance Analysis, Physical Demands, Process Improvement, Process Management, Project/Program Management, Public Health, Quality Management, Regulatory Compliance, Relationship Management, Risk, Sales Management, Social Security Administration, Strategic Planning, Telehealth, Vendor/Supplier Management, Vendor/Supplier Planning, Vendor/Supplier Quality Management, Vendor/Supplier Relations

LOCATION

Baton Rouge, LA

POSTED

3 days ago

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.

Residency in or relocation to Louisiana is preferred for all positions.

Position Purpose

The Director, Prospective Risk Adjustment Operations leads the organization's prospective risk adjustment accuracy strategy and execution across Medicare Advantage and ACA products. This role is accountable for the design, implementation, and optimization of provider-facing and member-facing programs that ensure complete, accurate, and compliant documentation of member health status at the point of care. The Director oversees Clinical Documentation Integrity (CDI), provider engagement, Annual Wellness Visit initiatives, in-home and telehealth assessment programs, and other prospective risk adjustment interventions designed to drive accurate HCC capture and improve risk adjustment outcomes.

How You Contribute to the Company's Mission in this Role

Strategic Leadership

+ Leads the development and execution of enterprise-wide prospective risk adjustment operational strategies.

+ Translates analytical insights into scalable operational programs that improve documentation accuracy, provider engagement, and member participation.

+ Establishes performance goals, operational metrics, and accountability measures to achieve enterprise risk adjustment objectives.

Provider-Facing Prospective Coding Accuracy Programs

+ Oversees all provider-facing prospective HCC coding accuracy programs.

+ Develops, deploys, and scales Clinical Documentation Integrity (CDI) programs focused on suspected and previously coded conditions, practice transformation initiatives, and payer-provider process integration.

+ Engages providers to improve documentation quality and coding accuracy through education, performance reporting, and consultative support.

+ Aligns provider incentive structures with coding accuracy objectives and broader quality improvement programs.

Member-Facing Coding Accuracy Programs

+ Leads initiatives designed to improve member participation in prospective risk adjustment activities.

+ Oversees integration of Annual Wellness Visit outreach efforts into existing member engagement programs.

+ Develops new outreach strategies targeting members at risk of non-engagement.

+ Oversees Comprehensive Health Evaluation programs, including in-home and telehealth health assessments.

Cross-Functional Collaboration

+ Collaborates with healthcare analytics, provider organizations, value-based care teams, population health, compliance, and clinical leadership to advance prospective risk adjustment goals.

+ Partners with internal stakeholders to integrate risk adjustment communications and interventions throughout the member lifecycle.

+ Builds and maintains relationships with vendors and strategic partners that support prospective coding accuracy initiatives.

Operational Excellence

+ Owns operational infrastructure, workflows, performance management processes, and vendor oversight necessary to achieve program objectives.

+ Monitors and drives performance related to prospective HCC recapture, provider coding accuracy, Annual Wellness Visit completion, in-home assessment completion, and provider engagement outcomes.

+ Ensures all programs operate in accordance with regulatory and compliance requirements.

Required Qualifications

Education

+ Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Nursing, Finance, or a related field required.

+ Master's degree preferred.

Experience

+ Seven (7) years of progressive leadership experience in risk adjustment, population health, provider engagement, healthcare operations, value-based care, or a related healthcare function.

+ Experience developing and leading provider-facing initiatives designed to improve documentation quality, coding accuracy, and operational performance.

+ Demonstrated experience leading large-scale operational programs and cross-functional teams.

+ Experience working with Medicare Advantage, ACA, risk adjustment methodologies, HCC coding, and healthcare reimbursement programs preferred.

Knowledge, Skills, and Abilities

+ Strong knowledge of prospective risk adjustment principles, HCC coding methodologies, and documentation integrity practices.

+ Understanding of provider engagement strategies, population health management, and value-based care models.

+ Ability to analyze complex operational and performance data and translate findings into actionable business strategies.

+ Strong communication, relationship management, and influencing skills.

+ Demonstrated ability to lead organizational change and drive measurable results through cross-functional collaboration.

+ Strong project management, process improvement, and vendor management skills.

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.

Perform other job-related duties as assigned, within your scope of responsibilities.

Job duties are performed in a normal and clean office environment with normal noise levels.

Work is predominately done while standing or sitting.

The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

All internal employees please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

_We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner._

_Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results._

JOB CATEGORY:General Management Group

About the Company

Blue Cross and Blue Shield of Louisiana

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