Optum NY, is seeking an Executive Director of Risk Adjustment join our team in New York, NY. The Executive Director of Risk Adjustment is responsible for leading the strategic execution and operational performance of enterprise-wide risk adjustment programs across Optum East. This role ensures accurate, compliant, and sustainable risk capture across employed and contracted provider networks, directly impacting financial performance in value-based arrangements.
This leader partners closely with provider organizations, clinical leadership, coding teams, and enterprise stakeholders to embed risk capture into clinical workflows while maintaining regulatory compliance and audit readiness.
Primary Responsibilities: - Risk Adjustment Strategy & Execution
- Lead enterprise risk adjustment strategy for Medicare Advantage, Medicaid, and Commercial risk contracts
- Drive accurate and sustainable RAF performance through prospective and retrospective programs
- Develop multi-year roadmap for risk capture, documentation improvement, and coding optimization
- Provider Partnership & Engagement
- Serve as a strategic advisor to provider groups on documentation and coding performance
- Partner with physician leaders and practice executives to embed risk workflows into care delivery
- Co-develop actionable performance plans to close documentation and coding gaps
- Coding Excellence & Program Oversight
- Oversee coding programs including chart review, CDI, education, and audit processes
- Ensure adherence to ICD-10, CMS-HCC, and state-specific risk methodologies
- Standardize best practices across employed and independent networks
- Compliance & Audit Readiness
- Ensure compliance with CMS, HHS, and state regulatory requirements
- Partner with compliance and legal on audits, RADV readiness, and corrective actions
- Serve as escalation point for risk-related regulatory matters
- Data, Analytics & Reporting
- Drive actionable reporting on RAF performance, coding accuracy, and documentation trends
- Partner with analytics teams to identify risk opportunities and provider-level insights
- Implement dashboards to track prospective and retrospective program effectiveness
- Operational Effectiveness
- Standardize workflows across coding, chart abstraction, and outreach activities
- Improve efficiency and reduce provider abrasion tied to documentation processes
- Coordinate with Quality teams to align provider touchpoints where appropriate
- Financial Performance Alignment
- Partner with finance and actuarial teams to model and track RAF impact
- Ensure providers understand financial implications of risk capture performance
- Support success in shared savings, capitation, and global risk contracts
- Team Leadership
- Lead high-performing teams across coding, CDI, analytics, and risk operations
- Build a culture of accountability, compliance, and continuous improvement
Key Performance Indicators (KPIs):- RAF accuracy and year-over-year improvement
- Coding accuracy and audit results
- Provider engagement in risk programs
- Closure of suspect and retrospective gaps
- Financial performance tied to risk adjustment
- Regulatory compliance and audit outcomes
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications: - 10+ years of expereince in risk adjustment, coding, or value-based care
- Experience working with provider organizations in risk-bearing models
- Deep expertise in CMS-HCC, ICD-10, and documentation standards
- Solid understanding of regulatory audits and compliance frameworks
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $134,600 - $230,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.
