Risk Adjustment Compliance, Sr. Principal

Your Role

The Risk Adjustment Compliance team plays a critical role in ensuring that Blue Shield maintains appropriate adherence to federal and state regulations. The Director, Risk Adjustment Compliance will report to the Senior Director, Government Programs Compliance. In this role you will provide strategic leadership and management of the department overseeing compliance with regulations and laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare lines of business, which includes implementation of elements of an effective compliance program.

You will oversee the development of risk assessments oversight and the monitoring of work plans pertaining to Risk Adjustment and partner with business areas to ensure and implement effective prevention, detection and correction of compliance issues.

• Requires a bachelor's degree in business administration, Public Policy, Public Health, Health Administration, related field, or equivalent experience required.
• Master's Degree CPA, CISA, JD, MHA, MBA, MIS or equivalent experience preferred
• Requires 10+ years compliance experience, with increasing responsibility for risk adjustment coding or related compliance functions in a health plan environment, with CMS, DHCS, and state Medicaid/Medi-Cal regulations
• Requires at least 6 years of management experience as a people leader with direct reports.
• Requires proven experience with RADV audits, prospective and retrospective chart reviews, encounter data, claims submissions, OIG investigations, False Act implications, and provider education
• Requires deep understanding of CMS‑HCC, CDPS+Rx, and ACA risk adjustment models
• Requires solid understanding in ICD‑10, CPT, and HCC coding
• Requires familiarity with RAF (Risk Adjustment Factor) calculations and their financial implications
• CRC, CCS, RHIT or similar coding certifications required, HCCA certification (CHC) or equivalent preferred
• Requires demonstrated ability to lead and influence in a large matrixed organization, and experience working with senior executives