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Director, Risk Adjustment
PacificSource Health Plans. Establish and maintain enterprise risk adjustment strategy, governance, and control framework .
Tech Stack
Tools & technologiesCloudSQL
About the role
Key responsibilities & impact- Establish and maintain enterprise risk adjustment strategy, governance, and control framework
- Define performance measures, operating cadence, roles, responsibilities, and resourcing for compliant data submission
- Develop scalable prospective engagement and education programs to improve documentation and diagnosis reporting
- Support member engagement strategies aligned with improved health outcomes
- Oversee provider feedback, Annual Wellness Visit insights, and Coding team education
- Oversee Medicare Advantage risk adjustment submissions, including EDS, and support ACA EDGE Server activities
- Lead risk adjustment analytics, including risk score and submission monitoring, reporting, analytics, forecasting, and scenario modeling
- Ensure audit readiness and response for internal and external audits, including MA and HHS RADV
- Lead risk adjustment coding operations, medical record retrieval, retrospective and prospective coding/validation, and compliance controls
- Manage hiring, coaching, performance, productivity, competency development, and succession planning for risk adjustment roles
- Direct departmental budgeting and vendor selection, contracting, and performance management
- Build partnerships with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other internal teams
- Participate in strategic initiatives, internal committees, leadership meetings, and the annual Medicare Bid process
- Meet department and company performance and attendance expectations
- Follow PacificSource privacy policy and HIPAA laws and regulations
- Perform other duties as assigned
Requirements
What you’ll need- Minimum of 5 years of experience in a healthcare setting
- At least 3 years directly related to risk adjustment
- 3 years of team management experience
- Deep knowledge of prospective and retrospective risk adjustment tools, data submission guidelines, and provider engagement approaches
- Experience managing vendor relationships preferred
- Familiarity with pricing models across lines of business and value-based contracts with provider groups
- Preferred experience with Medicaid, Medicare, and Commercial health plan operations
- Bachelor’s degree required
- Advanced degree preferred
- In-depth knowledge of CMS risk adjustment regulations, HHS ACA rules, Medicaid methodologies, and CMS coding standards
- Strong quantitative data analysis, statistical modeling, and advanced analytical methods
- Proficiency in SQL, data analysis/reporting tools, statistical software such as SAS, cloud-based platforms, performance measurement, and cost analysis
- Understanding of database structures, relational concepts, data architecture, and Epic
- Executive-level communication, facilitation, and presentation skills
- Ability to read and comprehend written and spoken English
- Ability to communicate clearly and effectively
- Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and lift/carry files and business materials
Benefits
Comp & perks- Equal opportunity employment
- Travel approximately 10% of the time
- General office setting with ergonomically configured equipment