Sr. Director - Risk Adjustment

Description

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Develop and execute enterprise-wide risk adjustment and documentation improvement strategies aligned with organizational and value-based care objectives.
• Establish departmental goals, key performance indicators (KPIs), and operational plans that drive measurable improvements in risk capture, coding accuracy, provider engagement, and financial performance.
• Identify opportunities to enhance revenue integrity, operational efficiency, and program effectiveness through innovative solutions and data-driven decision making.
• Provide leadership and guidance on emerging regulatory requirements, risk adjustment methodologies, and industry best practices.

• Provide oversight of risk adjustment, coding, provider education, documentation improvement, retrospective review, and prospective outreach programs.
• Ensure consistent implementation of operational standards, workflows, and performance expectations across all markets and business units.
• Lead cross-functional initiatives involving clinical services, provider operations, analytics, quality, compliance, and finance teams.
• Monitor program outcomes and implement strategic improvements to maximize organizational performance.

• Accountable for achievement of risk adjustment, quality, productivity, compliance, and financial performance goals.
• Develop and manage departmental budgets, workforce planning, resource allocation, and vendor expenditures.
• Evaluate operational trends, performance metrics, and financial results to identify opportunities for growth and process improvement.
• Implement corrective action plans when performance objectives are not being achieved.

• Build and maintain strategic relationships with executive leadership, provider groups, health plans, vendors, and external stakeholders.
• Partner with providers and operational leaders to support documentation excellence, coding accuracy, and value-based care success.
• Present business performance, strategic recommendations, and operational results to senior leadership and executive stakeholders.
• Oversee vendor management activities, including performance monitoring, contract compliance, and service delivery expectations.

• Ensure organizational compliance with CMS, NCQA, DMHC, HHS, and other applicable federal, state, and health plan requirements.
• Oversee internal monitoring, audits, and regulatory review activities related to risk adjustment and documentation practices.
• Collaborate with compliance and quality teams to implement corrective actions and continuous improvement initiatives.
• Promote a culture of ethical documentation, coding integrity, and regulatory compliance.

• Provides direct leadership and oversight to Senior Managers, Managers, and departmental leadership teams responsible for risk adjustment operations, coding, provider engagement, analytics, and program administration.
• Establishes strategic direction, performance expectations, and operational priorities across multiple functional areas and levels of leadership.
• Coaches, mentors, and develops leaders to strengthen organizational capability, succession planning, and employee engagement.
• Evaluates organizational structure and staffing needs to ensure resources are appropriately aligned with business objectives and growth strategies.
• Drives a culture of accountability, collaboration, innovation, and continuous improvement throughout the department.
• Oversees talent management activities including recruitment, performance management, employee development, succession planning, and leadership development.
• Ensures consistency in management practices, employee engagement, and performance standards across all teams and markets.
• Partners with executive leadership to anticipate future workforce needs and develop organizational capabilities that support long-term strategic objectives.  
• Other duties as assigned.

Qualifications

• Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Nursing, Health Information Management, or related field required.
• Master's degree preferred.
• At least 10 years of healthcare operations, risk adjustment, managed care, or population health experience. 
• At least 5 years of progressive leadership experience managing multiple teams or programs. 
• Demonstrated experience leading large-scale value-based care or risk adjustment initiatives. 
• One or more of the following certifications preferred: CRC, CPC, CCS, RHIA, RHIT
• Expert knowledge of CMS-HCC, Medicare Advantage, ACA, Medicaid, and value-based reimbursement methodologies.
• Strong understanding of risk adjustment operations, clinical documentation improvement, coding compliance, and healthcare analytics.
• Advanced knowledge of CMS, NCQA, DMHC, and other regulatory requirements impacting value-based care programs.
• Demonstrated ability to develop and execute strategic initiatives that improve organizational and financial performance.
• Strong business acumen, financial management, and operational leadership capabilities.
• Exceptional analytical and problem-solving skills with the ability to interpret complex healthcare data and translate findings into actionable strategies.
• Proven ability to influence and collaborate effectively with executive leaders, physicians, providers, and cross-functional stakeholders.
• Excellent verbal, written, presentation, and negotiation skills.
• Strong project management and change management capabilities.
• Experience leading large, geographically dispersed teams and complex healthcare programs.

Environmental Job Requirements and Working Conditions

• This is a remote position. Travel is required to provider offices across all of our US markets, health plan meetings organizational events, and to corporate offices in Southern California and Houston.
• The total compensation target pay range for this role is $160,000 - $195,000 per year. Total compensation will be evaluated based on experience, certifications, and skillsets.