Director, Risk Adjustment

PacificSource Health Plans

. Report to the Vice President of Quality and Population Health .

Posted 10/22/2026full-timeRemote • Tennessee • United StatesLead💰 $127,338 - $216,475 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in risk adjustment strategy, governance, and compliance within healthcare settings, with a strong focus on data analysis, coding standards, and team management. Proficient in leading cross-functional collaborations to enhance health outcomes and ensure audit readiness.

Highest-signal resume keywords

Risk Adjustment Strategy DevelopmentTeam Management ExperienceCMS Risk Adjustment Regulations KnowledgeSQL ProficiencyQuantitative Data Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Risk Adjustment ToolsData Submission GuidelinesStatistical ModelingCoding StandardsData ArchitectureProspective CodingRetrospective CodingCompliance ControlsVendor ManagementPerformance Measurement

Soft Skills

Executive-Level CommunicationFacilitation SkillsPresentation SkillsClear Communication

Tools & Technologies

SQLSASEpicData Analysis/Reporting ToolsCloud-Based Platforms

Industry Keywords

Medicare AdvantageHHS ACA RulesMedicaid MethodologiesValue-Based ContractsHealthcare Operations

Tech Stack

Tools & technologies

CloudSQL

About the role

Key responsibilities & impact

Report to the Vice President of Quality and Population Health
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 and wraparound services aligned with improved health outcomes
Oversee provider feedback, Annual Wellness Visit insights, and Coding team education
Design annual education strategies with the Population Health Director
Oversee end-to-end Medicare Advantage risk adjustment submissions, including EDS
Support ACA EDGE Server activities
Lead risk adjustment analytics, including risk score and submission monitoring, reporting, and analytics
Partner with Actuarial, Finance, and IT on reconciliation, forecasting, and scenario modeling
Ensure audit readiness and responses for MA and HHS RADV audits
Oversee documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development
Lead risk adjustment coding workflows, 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 across Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other teams
Participate in strategic initiatives, internal committees, leadership meetings, and the annual Medicare Bid process
Meet department and company performance and attendance expectations
Follow privacy policy and HIPAA confidentiality and security requirements
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 preferred
Preferred experience with Medicaid, Medicare, and Commercial health plan operations
Strategic planning and system design experience in health plan environments preferred
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, and cloud-based platforms
Knowledge of database structures, relational concepts, and data architecture
Experience using 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 light lifting/carrying

Benefits

Comp & perks

Equal opportunity employment
Work inside in a general office setting with ergonomically configured equipment
Travel required approximately 10% of the time
Participation in internal committees and leadership meetings
Managerial forums and leadership development opportunities