Director, Risk Adjustment

Location: California

Responsible for ensuring the organization has a comprehensive, efficient and compliant documentation integrity program (risk adjustment and HEDIS/Stars Quality measure documentation). Works directly with clinicians, certified coders, IT, enterprise analytics, network management and physicians. Owns accountability for ensuring our members’ medical record is complete, accurate and represents accurate member conditions. This role will work closely with the Quality/Accreditation teams, Customer Service and Call Center Teams, Provider Services Team, Nurse Practitioners, and Clinical Program Teams.

Applies in-depth knowledge of risk adjustment methodology to partner with key stakeholders in improving outcomes

Provider profiling, engagement and education programs

Develops and implements provider education strategies and tools, monitors provider performance, develops improvement plans and assists physicians/care teams to ensure patients are accurately assessed for medical conditions

Composes and distributes education materials to physicians and vendors to aid the collection of complete and accurate member profile documentation

Stays informed of all risk related program requirements from CMS and develop implementation strategies to CMS requirements

Performs management responsibilities including hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity; has budgetary responsibility and authority
10 or more years related experience including: 5+ years of experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.
5+ years of experience in risk adjustment and HEDIS/STARS (Medicare Advantage/commercial).5+ years of experience with Chart Review, In Home assessment, Provider education, Prospective programs and encounter submissions; knowledge of billing rules and systems6 years of management experience 5 years of demonstrated experience with reporting and analytical tools (power BI, Tableau, etc)
Experience driving results and influencing across a wide array of stakeholders Risk Adjustment experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.

Knowledge within RAF markets (Medicare Advantage/commercial).HEDIS/STARS data abstraction and reporting experience in Managed Care, large medical group / IPA, Payer Provider Health Plan, Health system management.

Chart Review, Annual Health Assessment (AHA/AWV), Provider education, Prospective programs and encounter submissions; knowledge of billing rules and systems

Management experience and ability to be a servant leader who rolls up their sleeves to both do the work, coach the team, and be a strategic thinker to drive the program forward

Deep analytical skills to leveraging data to formulate insights and drive decisions. This includes manipulating and understanding data to craft data-driven messages, as well as thinking of new ways to draw insights from data.

Strong skills in influencing without authority
* Expert at building relationships with a broad range of internal and external stakeholders.
** Base Salary**$165,000 - $220,000/yr
** You Share Our Mission & Values:
**** Compassion
* * We act with empathy and a deep respect for the challenges faced by physicians and their patients. Our work is driven by a genuine commitment to improving lives and ensuring that care is delivered with dignity, understanding, and humanity.
** Community
* * We foster a culture of collaboration--with physicians, patients across the healthcare ecosystem, and among our teams. By building strong, trusted relationships, we create a unified community focused on advancing patient care and physician well-being.
** Leadership
* * We lead with integrity and vision, setting the standard for excellence in physician support and healthcare innovation. Through collaboration and expertise, we empower others to lead, drive change, and shape the future of care.
** Excellence
* * We are relentlessly focused, results-driven, and accountable for delivering measurable value to physicians and the patients they serve. Our high standards reflect our…