Position PurposeThe Director, Prospective Risk Adjustment Operations leads the organization's prospective risk adjustment accuracy strategy and execution across Medicare Advantage and ACA products. This role is accountable for the design, implementation, and optimization of provider-facing and member-facing programs that ensure complete, accurate, and compliant documentation of member health status at the point of care. The Director oversees Clinical Documentation Integrity (CDI), provider engagement, Annual Wellness Visit initiatives, in-home and telehealth assessment programs, and other prospective risk adjustment interventions designed to drive accurate HCC capture and improve risk adjustment outcomes.
How You Contribute to the Company's Mission in this RoleStrategic Leadership- Leads the development and execution of enterprise-wide prospective risk adjustment operational strategies.
- Translates analytical insights into scalable operational programs that improve documentation accuracy, provider engagement, and member participation.
- Establishes performance goals, operational metrics, and accountability measures to achieve enterprise risk adjustment objectives.
Provider-Facing Prospective Coding Accuracy Programs- Oversees all provider-facing prospective HCC coding accuracy programs.
- Develops, deploys, and scales Clinical Documentation Integrity (CDI) programs focused on suspected and previously coded conditions, practice transformation initiatives, and payer-provider process integration.
- Engages providers to improve documentation quality and coding accuracy through education, performance reporting, and consultative support.
- Aligns provider incentive structures with coding accuracy objectives and broader quality improvement programs.
Member-Facing Coding Accuracy Programs- Leads initiatives designed to improve member participation in prospective risk adjustment activities.
- Oversees integration of Annual Wellness Visit outreach efforts into existing member engagement programs.
- Develops new outreach strategies targeting members at risk of non-engagement.
- Oversees Comprehensive Health Evaluation programs, including in-home and telehealth health assessments.
Cross-Functional Collaboration- Collaborates with healthcare analytics, provider organizations, value-based care teams, population health, compliance, and clinical leadership to advance prospective risk adjustment goals.
- Partners with internal stakeholders to integrate risk adjustment communications and interventions throughout the member lifecycle.
- Builds and maintains relationships with vendors and strategic partners that support prospective coding accuracy initiatives.
Operational Excellence- Owns operational infrastructure, workflows, performance management processes, and vendor oversight necessary to achieve program objectives.
- Monitors and drives performance related to prospective HCC recapture, provider coding accuracy, Annual Wellness Visit completion, in-home assessment completion, and provider engagement outcomes.
- Ensures all programs operate in accordance with regulatory and compliance requirements.
Required QualificationsEducation- Bachelor's degree in Healthcare Administration, Business Administration, Public Health, Nursing, Finance, or a related field required.
- Master's degree preferred.
Experience- Seven (7) years of progressive leadership experience in risk adjustment, population health, provider engagement, healthcare operations, value-based care, or a related healthcare function.
- Experience developing and leading provider-facing initiatives designed to improve documentation quality, coding accuracy, and operational performance.
- Demonstrated experience leading large-scale operational programs and cross-functional teams.
- Experience working with Medicare Advantage, ACA, risk adjustment methodologies, HCC coding, and healthcare reimbursement programs preferred.
Knowledge, Skills, and Abilities- Strong knowledge of prospective risk adjustment principles, HCC coding methodologies, and documentation integrity practices.
- Understanding of provider engagement strategies, population health management, and value-based care models.
- Ability to analyze complex operational and performance data and translate findings into actionable business strategies.
- Strong communication, relationship management, and influencing skills.
- Demonstrated ability to lead organizational change and drive measurable results through cross-functional collaboration.
- Strong project management, process improvement, and vendor management skills.
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.
Perform other job-related duties as assigned, within your scope of responsibilities.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document, calculate, visualize, and analyze are required.
