Director, Risk Adjustment

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* Join Pacific Source and help our members access quality, affordable care!
*** Pacific Source is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.
** Pacific Source values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Director of Risk Adjustment, reporting to the Vice President of Quality and Population Health, is responsible for ensuring accurate, complete, and compliant Risk Adjustment data reporting to CMS and for leading enterprise-wide risk adjustment programs across all lines of business to identify risk exposure and optimization opportunities. This role oversees an Analytic Manager and Coding Manager that are accountable for cross functional operating team model including analytics and reporting, medical record retrieval, retrospective and prospective coding operations, and provider engagement while ensuring adherence to official guidelines and industry best practices.

They partner closely with providers, vendors, and clinical leaders to enhance documentation and coding accuracy through measurable improvement initiatives, and collaborate with Finance, IT, Operations, and Quality to streamline processes, leverage analytics, and implement compliant optimization strategies. Key accountabilities include program design and management, vendor oversight, provider and member outreach when applicable, and leadership of business intelligence efforts supporting Medicare Advantage, ACA Commercial, and Medicaid risk adjustment performance.
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* Essential Responsibilities:

*** Establish and maintain the enterprise risk adjustment strategy, governance, and control framework—defining performance measures, operating cadence, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs.
* Develop and implement scalable prospective programs engagement and education programs dedicated to driving continuous quality improvement in documentation and diagnosis reporting, with transparent feedback loops and measurable objectives in value-based care
* Support member engagement strategies to strengthen engagement and wrap around services aligned with improved health outcomes.
* Oversee risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education, while collaborating with the Population Health Director to design annual education strategies and foster partnerships anchored in quality and value.
* Oversee end to end Medicare Advantage risk adjustment submissions (including EDS) and support ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation integrity, provider engagement, and full compliance with official coding guidelines and program requirements.
* Lead the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and IT on data reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure robust data lineage, operational insights, and audit readiness.
* Ensure audit readiness and response for internal and external audits (MA and HHS RADV), overseeing documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development.
* Lead the Risk Adjustment Coding function and core operational workflows—including medical record retrieval, retrospective and prospective…