Director, Risk Adjustment

PACIFICSOURCE

. Establish and maintain the enterprise risk adjustment strategy, governance, and control framework .

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 strategies, including compliance with CMS regulations and HHS ACA rules, while effectively managing teams and vendor relationships. Proficient in data analysis and reporting, with strong communication skills to engage stakeholders and support health outcomes.

Highest-signal resume keywords

Risk Adjustment Strategy DevelopmentTeam Management ExperienceCMS Risk Adjustment Regulations KnowledgeSQL ProficiencyStatistical Software Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Risk Adjustment StrategiesData Submission GuidelinesStatistical ModelingPerformance MeasurementCost AnalysisDatabase StructuresData ArchitectureCoding StandardsVendor ManagementProblem Solving

Soft Skills

Executive-Level CommunicationFacilitation SkillsCollaborative Relationship BuildingCreative Problem Solving

Tools & Technologies

SQLSASEpicCloud-Based Platforms

Industry Keywords

Healthcare SettingMedicare AdvantageMedicaid MethodologiesCommercial Health Plan OperationsHIPAA ComplianceValue-Based Contracts

Tech Stack

Tools & technologies

CloudSQL

About the role

Key responsibilities & impact

Establish and maintain the enterprise risk adjustment strategy, governance, and control framework
Define performance measures, operating cadence, roles and responsibilities, and resourcing for accurate, complete, and compliant data submission
Develop and implement 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
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, scenario modeling, regulatory impacts, and payment methodologies
Ensure audit readiness and response 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 and operational workflows, including medical record retrieval, retrospective and prospective coding/validation, and coding guideline adherence
Lead hiring, coaching, performance management, competency development, and succession planning
Direct departmental budgeting and vendor oversight, including 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 internal committees and leadership meetings
Support the annual Medicare Bid process
Serve as an active member of managerial forums
Meet department and company performance and attendance expectations
Follow PacificSource privacy policy and HIPAA laws and regulations
Perform other duties as assigned
Report to the Vice President of Quality and Population Health

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 risk adjustment strategies, including prospective and retrospective tools, data submission guidelines, and provider engagement approaches
Experience managing vendor relationships preferred
Familiarity with pricing models across lines of business and influencing or managing value based contracts with provider groups
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
Ability to analyze quantitative data from multiple sources using statistical modeling and advanced analytical methods
Proficiency in SQL and other data analysis/reporting tools
Proficiency in statistical software, such as SAS and cloud-based platforms
Knowledge of performance measurement, cost analysis, database structures, relational concepts, and data architecture
Experience using Epic to enhance efficiency
Ability to define problems, evaluate data, draw sound conclusions, and apply creative problem solving to complex business issues
Executive-level communication, facilitation, and presentation skills
Ability to build trust and collaborative relationships with key stakeholders
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
Must follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

Benefits

Comp & perks

Equal opportunity employment
Work-from-home arrangement
Ergonomically configured equipment
Travel opportunities/required travel approximately 10% of the time