Sr. Director - Risk AdjustmentDepartment: Quality - Risk Adjustment
Employment Type: Full Time
Location: 1668 S. Garfield Ave. 2nd Floor, Alhambra, CA 91801
Reporting To: Nallammai Vijayakumar
Compensation: $160,000 - $195,000 / year
DescriptionWe are seeking a strategic and dynamic leader to drive the organization's risk adjustment, clinical documentation improvement, provider engagement, and population health strategies. This role will lead multiple layers of leadership, including Senior Managers, Managers, and their teams, while translating enterprise priorities into meaningful operational results.
The ideal leader will build and develop high-performing teams, cultivate strong leadership talent, and foster collaboration across the organization. With a focus on innovation, operational excellence, and value-based care, this individual will play a key role in advancing risk adjustment accuracy, regulatory compliance, provider performance, and overall population health outcomes.
What You'll DoStrategic Leadership- Develop and execute enterprise-wide risk adjustment and documentation improvement strategies aligned with organizational and value-based care objectives.
- Establish departmental goals, key performance indicators (KPIs), and operational plans that drive measurable improvements in risk capture, coding accuracy, provider engagement, and financial performance.
- Identify opportunities to enhance revenue integrity, operational efficiency, and program effectiveness through innovative solutions and data-driven decision making.
- Provide leadership and guidance on emerging regulatory requirements, risk adjustment methodologies, and industry best practices.
Program Oversight- Provide oversight of risk adjustment, coding, provider education, documentation improvement, retrospective review, and prospective outreach programs.
- Ensure consistent implementation of operational standards, workflows, and performance expectations across all markets and business units.
- Lead cross-functional initiatives involving clinical services, provider operations, analytics, quality, compliance, and finance teams.
- Monitor program outcomes and implement strategic improvements to maximize organizational performance.
Financial and Operational Management- Accountable for achievement of risk adjustment, quality, productivity, compliance, and financial performance goals.
- Develop and manage departmental budgets, workforce planning, resource allocation, and vendor expenditures.
- Evaluate operational trends, performance metrics, and financial results to identify opportunities for growth and process improvement.
- Implement corrective action plans when performance objectives are not being achieved.
Provider and Stakeholder Management- Build and maintain strategic relationships with executive leadership, provider groups, health plans, vendors, and external stakeholders.
- Partner with providers and operational leaders to support documentation excellence, coding accuracy, and value-based care success.
- Present business performance, strategic recommendations, and operational results to senior leadership and executive stakeholders.
- Oversee vendor management activities, including performance monitoring, contract compliance, and service delivery expectations.
Regulatory Compliance and Quality- Ensure organizational compliance with CMS, NCQA, DMHC, HHS, and other applicable federal, state, and health plan requirements.
- Oversee internal monitoring, audits, and regulatory review activities related to risk adjustment and documentation practices.
- Collaborate with compliance and quality teams to implement corrective actions and continuous improvement initiatives.
- Promote a culture of ethical documentation, coding integrity, and regulatory compliance.
Leadership and Talent Development- Provides direct leadership and oversight to Senior Managers, Managers, and departmental leadership teams responsible for risk adjustment operations, coding, provider engagement, analytics, and program administration.
- Establishes strategic direction, performance expectations, and operational priorities across multiple functional areas and levels of leadership.
- Coaches, mentors, and develops leaders to strengthen organizational capability, succession planning, and employee engagement.
- Evaluates organizational structure and staffing needs to ensure resources are appropriately aligned with business objectives and growth strategies.
- Drives a culture of accountability, collaboration, innovation, and continuous improvement throughout the department.
- Oversees talent management activities including recruitment, performance management, employee development, succession planning, and leadership development.
- Ensures consistency in management practices, employee engagement, and performance standards across all teams and markets.
- Partners with executive leadership to anticipate future workforce needs and develop organizational capabilities that support long-term strategic objectives.
- Other duties as assigned.
Qualifications- Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Nursing, Health Information Management, or related field required.
- Master's degree preferred.
- At least 10 years of healthcare operations, risk adjustment, managed care, or population health experience.
- At least 5 years of progressive leadership experience managing multiple teams or programs.
- Demonstrated experience leading large-scale value-based care or risk adjustment initiatives.
- One or more of the following certifications preferred: CRC, CPC, CCS, RHIA, RHIT
- Expert knowledge of CMS-HCC, Medicare Advantage, ACA, Medicaid, and value-based reimbursement methodologies.
- Strong understanding of risk adjustment operations, clinical documentation improvement, coding compliance, and healthcare analytics.
- Advanced knowledge of CMS, NCQA, DMHC, and other regulatory requirements impacting value-based care programs.
- Demonstrated ability to develop and execute strategic initiatives that improve organizational and financial performance.
- Strong business acumen, financial management, and operational leadership capabilities.
- Exceptional analytical and problem-solving skills with the ability to interpret complex healthcare data and translate findings into actionable strategies.
- Proven ability to influence and collaborate effectively with executive leaders, physicians, providers, and cross-functional stakeholders.
- Excellent verbal, written, presentation, and negotiation skills.
- Strong project management and change management capabilities.
- Experience leading large, geographically dispersed teams and complex healthcare programs.
Environmental Job Requirements and Working Conditions- This is a remote position. Travel is required to provider offices across all of our US markets, health plan meetings organizational events, and to corporate offices in Southern California and Houston.
- The total compensation target pay range for this role is $160,000 - $195,000 per year. Total compensation will be evaluated based on experience, certifications, and skillsets.
Additional Information:The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
