Director, Risk Adjustment Prospective Programs

IEHP

. Implement, operationalize, optimize, and scale prospective risk adjustment programs, including point-of-care, in-home, virtual, and concurrent assessment initiatives .

Posted 10/9/2026full-timeRancho Cucamonga • California • United StatesLead💰 $154,128 - $204,214 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive experience in healthcare managed care and risk adjustment operations, with a focus on implementing prospective programs and ensuring compliance through effective documentation and EHR integration. Proven leadership in managing teams, vendor relationships, and performance metrics to drive quality outcomes.

Highest-signal resume keywords

Risk Adjustment OperationsEHR IntegrationLeadership and ManagementCertified Risk Adjustment Coder (CRC)Data Literacy with Excel/BI Tools

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prospective Risk Adjustment ProgramsCompliant Documentation CaptureICD-10-CM/HCC KnowledgeProgram ManagementChange ManagementAnalytics SkillsPerformance MetricsBudget StewardshipVendor ManagementEDPS Submission Mechanics

Soft Skills

Presentation SkillsFacilitation SkillsCollaborationRelationship ManagementChange Leadership

Tools & Technologies

EpicAthenaEClinicalWorksBI Tools

Certifications & Qualifications

Certified Risk Adjustment Coder (CRC)Certified Professional Coder (CPC)CDI Certification

Industry Keywords

Healthcare OperationsManaged CareBehavioral Change CampaignsHEDISRADV Readiness

About the role

Key responsibilities & impact

Implement, operationalize, optimize, and scale prospective risk adjustment programs, including point-of-care, in-home, virtual, and concurrent assessment initiatives
Deliver historical chronic conditions and suspected HCC gaps to providers during member visits
Oversee in-home and virtual assessment strategy, vendor selection, campaigns, performance metrics, compliance, and care-management integration
Build EHR smart-phrases, discrete macros, and pre-visit planning summaries to reduce clinician administrative burden
Design and manage per-assessment incentive programs and quality bonus structures with Contracting and Provider Relations
Oversee provider education on CMS M.E.A.T. documentation criteria
Coordinate with delegated IPA Medical Directors to integrate suspecting data into care-gap and scheduling registries
Govern suspecting engines using claims, prescription, lab, and SDOH data; establish acceptance criteria and feedback loops
Segment the FFS network based on prospective actionability and prioritize point-of-care tools
Align risk-adjustment alerts with Quality/HEDIS care-gap alerts and establish clinical handoffs to Case Management and Disease Management
Oversee validation audits and ensure compliant documentation to mitigate RADV audit exposure
Coordinate end-to-end encounter/EDPS submission integrity and monitor transaction errors
Maintain dashboards for throughput, accuracy, timelines, and ROI; conduct root-cause analysis and remediation
Support vendor selection, contracting, performance management, SLA and data-security oversight, and ROI tracking
Manage budgets and resource allocations
Lead, develop, hire, train, and manage staff; oversee performance, workforce planning, reviews, and change leadership
Maintain SOPs, controls, audit trails, governance reporting, and continuous process and technology improvements
Perform other duties required to support Health Plan operations and department needs

Requirements

What you’ll need

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
Must have a valid California Driver’s license
Comprehensive knowledge of healthcare operations or behavioral change campaigns within a non-employed, independent FFS provider network
Knowledge of prospective risk adjustment platforms and EHR alert integrations (Epic, Athena, eClinicalWorks, etc.)
Experience managing large-scale national prospective/IHA vendors
Knowledge of program management, change management, stakeholder facilitation, vendor management, and budget stewardship
Knowledge of ICD-10-CM/HCC, MEAT, HIPAA/privacy, RADV readiness, and encounter/EDPS submission mechanics
Data literacy with Excel/BI tools and intermediate–advanced analytics skills
Strong presentation and facilitation skills for varied clinical audiences
Advanced ability to build peer-to-peer credibility with network physicians, lead change, collaborate cross-functionally, maintain professional relationships, prioritize resources, and drive measurable outcomes

Benefits

Comp & 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