Job SummaryThe Principal, Risk Adjustment, is a director-level strategic leader responsible for cross-functional collaboration to drive enterprise risk adjustment performance, supporting new market acquisition and expansion, and leading high-impact, scalable program initiatives from concept through execution. This role provides leadership across risk adjustment strategy, trend management, provider engagement, operational execution, compliance, vendor oversight & technology enablement. The role will drive cost saving measures, improve operational efficiencies, and increase provider engagement and regulatory compliance.
Essential Functions- Strategic Leadership & Market Expansion: Lead risk adjustment strategy for new market acquisition, expansion, and operational readiness. Assess market-specific risk adjustment opportunities, operational gaps, provider capabilities, and technology requirements. Develop & execute scalable risk adjustment playbooks for new & existing markets. Partner with executive leadership & cross-functional stakeholders to align risk adjustment strategies with enterprise growth, revenue integrity, quality & value-based care objectives. Ensures department policies, programs, and plans are consistent with and support Priority health's core values and mission.
- Program Development & Execution: Lead risk adjustment initiatives from ideation & business case development through implementation, monitoring & continuous improvement. Define program objectives, success metrics, timelines, resource needs, risks, and operational dependencies. Oversee & support implementation of prospective, concurrent & retrospective risk adjustment programs. Drive process standardization across markets and vendors. Monitor initiative performance & develop corrective action plans to close gaps in execution or outcomes.
- Trend Management & Performance Oversight: Lead trend management for all risk adjustment initiatives, including development, implementation, monitoring, reporting, and optimization. Analyze trends and financial impacts and make recommendations for gap closure. Partner with Analytics & Actuary teams to forecast performance, identify improvement opportunities, and quantify revenue impact. Develop executive-level reporting & dashboards to track performance against targets. Identify emerging risks, market variation, provider performance issues, data gaps, and operational barriers impacting risk adjustment outcomes.
- Provider Engagement & Technical Enablement: Lead implementation of provider-facing technical applications and workflows that support risk adjustment accuracy and documentation improvement. Partner with IDA/DS, Analytics, Clinical Operations, and external vendors and providers to integrate risk adjustment tools into EMR/EHR platforms and provider workflows. Ensure provider facing tools are scalable across markets. Collaborate with Provider Network and external providers to support adoption, training, workflow redesign and performance accountability.
- Operational Governance & Compliance: Establish governance, controls, and monitoring processes for risk adjustment initiatives & technology-enabled workflows. Ensure risk adjustment activities comply with CMS requirements, coding guidelines, documentation standards, HIPAA, and internal compliance policies. Partner with Compliance and Audit teams to support RADV readiness, internal audits, chart review governance, and remediation plans. Develop policies, procedures, operating models, and controls to support sustainable & compliant risk adjustment operations.
- Cross-Functional Leadership: Partner with market leadership, provider engagement, clinical operations, finance, actuarial, analytics, compliance, IDA/DS, product and vendor partners. Influence stakeholders across a matrixed organization to drive alignment, accountability, and execution. Lead steering committee updates, executive briefings, and cross-functional workgroups. Translate complex risk adjustment insights into actionable business strategies & operational priorities. Provide leadership, coaching, and direction to project teams, analysts, market partners, and operational stakeholders.
- Vendor & Partner Management: Lead and participate in evaluating, selecting and managing vendors supporting risk adjustment. Support defining vendor performance expectations, service-level metrics, implementation timelines, and quality standards. Monitor vendor outcomes, resolve issues, and ensure alignment with enterprise objectives and compliance requirements. Partner with procurement, legal, compliance, and finance on contracting, performance reviews, and ongoing governance.
Qualifications- Bachelor's Degree in business, health care administration or related clinical field. Required
- Master's Degree in business, health care administration or related clinical field. Preferred
- 12 years of relevant experience Strong Risk Adjustment and Project Management experience with a detailed understanding of Enterprise Risk Management & Risk Adjustment for MA & ACA LOB Required
- CRT-ScrumMaster, Certified (CSM) - Required
- CRT-Lean Six Sigma Black Belt Certification (CSSBB) - Preferred
- CRT-Project Management Professional (PMP) - PMI - Preferred
Physical Demands- Pallet to Waist (6" from floor) > 5 lbs: Seldom
- Waist to Waist > 5 lbs: Seldom
- Waist to Chest (below shoulder) > 5 lbs: Seldom
- Waist to Overhead > 5 lbs: Seldom
- Bilateral Carry > 5 lbs: Seldom
- Unilateral Carry > 5 lbs: Seldom
- Pushing Force > 5 lbs: Seldom
- Pulling Force > 5 lbs: Seldom
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
How Corewell Health cares for you- Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance
- Traditional and Roth retirement options with service contribution and match savings
- Eligibility for benefits is determined by employment type and status
Primary LocationSITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids
Department NameRisk Adjustment Executive - PH Managed Benefits
Employment TypeFull time
ShiftDay (United States of America)
Weekly Scheduled Hours40
Hours of Work40
Days WorkedMonday-Friday
Weekend FrequencyN/A
