Director Risk Adjustment (Peak Health)

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The Director of Risk Adjustment leads Peak Health's enterprise risk adjustment strategy and operations across all applicable lines of business. This role provides strategic direction and operational oversight to optimize accurate, complete, and compliant capture and submission of member risk data while supporting regulatory requirements, financial performance, and quality outcomes. The Director partners with clinical, provider, quality, actuarial, encounters, finance, compliance, IT, and other business leaders to develop and execute an integrated risk adjustment strategy and is accountable for establishing effective processes, controls, analytics, and performance management capabilities across the entire risk adjustment lifecycle.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field.

EXPERIENCE:

1. Eight (8) years of progressive experience in healthcare risk adjustment, health plan operations, coding, clinical documentation, or a related discipline.

2. Five (5) years of leadership experience.

 

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s degree in healthcare administration, business, health information management, nursing, public health, finance, or a related field.

EXPERIENCE:

1. Specific experience managing and leading risk adjustment programs in Medicare Advantage, Individual ACA, and/or Medicaid; experience across multiple lines of business strongly preferred.

 

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Develop and execute the enterprise risk adjustment strategy and governance framework across all applicable lines of business.

2. Monitor regulatory changes and emerging risk adjustment methodologies, translating them into operational strategies and process improvements.

3. Oversee programs supporting accurate diagnosis capture, medical record retrieval, chart review, coding, validation, and submission of risk adjustment data.

4. Establish and maintain coding standards, policies, procedures, and quality requirements across all applicable lines of business.

5. Oversee coding quality assurance, second-level reviews, audits, corrective action processes, coder productivity, key performance indicators, and compliance with applicable CMS, state, federal, and organizational requirements.

6. Develop and deploy risk adjustment value-based programs with key providers.

7. Develop and maintain an enterprise risk adjustment performance dashboard with key performance indicators covering impacts, coding accuracy, chart retrieval, documentation, submission, audit performance, and operational efficiency.

8. Partner with actuarial and finance teams to quantify the impact of risk adjustment operations on risk scores and improve projection accuracy for bids, pricing, forecasting and accruals.

9. Provide executive leadership with regular reporting on performance, risks, opportunities, and recommended actions.

10. Ensure organizational readiness for CMS Risk Adjustment Data Validation (RADV) audits and regulatory reviews.

11. Oversee relationships with external vendors supporting chart retrieval, coding, analytics, and other risk adjustment functions.

12. Lead, develop, and mentor risk adjustment leaders and teams, establishing clear objectives, performance expectations, and professional development plans.

 

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

SKILLS AND ABILITIES:

1. Excellent communication, analytical, organizational, and executive leadership skills.

2. Ability to manage multiple complex initiatives in a highly regulated and rapidly changing environment. 

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

500 PHH Administration