Director of Risk Adjustment

Position Summary:

The Director of Risk Adjustment & Analytics will lead the strategy, operations, and analytics for risk adjustment programs across Medicare Advantage (MA) and Affordable Care Act (ACA) lines of business. This role is responsible for ensuring accurate risk score capture, compliance with CMS and state regulations, and driving financial performance through data-driven insights. The ideal candidate will combine deep knowledge of risk adjustment methodologies with strong leadership and analytical skills to optimize revenue integrity and improve member health outcomes.

Key Responsibilities:

• Strategic Leadership:

  • Develop and execute risk adjustment strategies for MA and ACA products to maximize accuracy and compliance.
  • Partner with executive leadership to align risk adjustment initiatives with organizational goals.

• Program Oversight:

  • Manage end-to-end risk adjustment processes, including data submission, coding accuracy, and vendor relationships.
  • Ensure compliance with CMS and state regulatory requirements for risk adjustment and encounter data.

• Analytics & Reporting:

  • Lead the design and implementation of advanced analytics to monitor risk score trends, identify gaps, and forecast financial impact.
  • Provide actionable insights to improve coding accuracy, member engagement, and care management programs.

• Cross-Functional Collaboration:

  • Work closely with clinical, operations, finance, and IT teams to integrate risk adjustment strategies into broader organizational initiatives.
  • Serve as a subject matter expert for internal stakeholders on risk adjustment methodologies and regulatory changes.

• Team Leadership:

  • Build and mentor a high-performing team of analysts and program managers.
  • Foster a culture of innovation, accountability, and continuous improvement.

Qualifications:

• Education:

  • Bachelor's degree in Healthcare Administration, Business, Statistics, or related field required; Master's degree preferred.

• Experience:

  • 8+ years of experience in risk adjustment, healthcare analytics, or revenue management within a health plan or consulting environment.
  • Proven expertise in Medicare Advantage and ACA risk adjustment models (HCC, RxHCC, etc.).
  • Strong understanding of CMS guidelines, EDGE server processes, and encounter data submission.

• Skills:

  • Advanced proficiency in data analytics tools (SQL, SAS, Python, or similar).
  • Excellent leadership, communication, and stakeholder management skills.
  • Ability to translate complex data into actionable business strategies.