Molina Healthcare

VP, Risk Adjustment

Molina Healthcare • $150K — $200K *
Long Beach, CA 90805In-Person
Healthcare
11 - 15 years of experience
2 days ago
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Job Overview by Ladders

Qualifications

  • 12+ years of progressive experience in risk adjustment in managed care or health plan environments
  • 7+ years of management/leadership experience
  • Experience managing risk adjustment programs across Medicare Advantage, Medicaid, and ACA
  • Knowledge of CMS HCC methodology and RADV audit processes
  • Proven ability to oversee clinical data acquisition and chart review programs
  • Expertise in leading multi-vendor ecosystems in complex environments
  • Strong analytical skills with data interpretation capabilities
  • Excellent communication and stakeholder engagement skills

Responsibilities

  • Oversee risk adjustment programs across all business lines to ensure operational alignment
  • Lead program management for chart review, in-home assessments, and clinical programs
  • Act as primary interface for in-home assessment capabilities with internal teams and external vendors
  • Manage provider clinical programs ensuring compliance with documentation standards
  • Establish enterprise-wide coding standards and Clinical Documentation Improvement protocols
  • Oversee quality evaluation processes for coding accuracy and compliance
  • Govern data flows from coding vendors through quality assurance and encounter staging
  • Ensure timely, accurate submission of encounter records across business lines
  • Develop tracking mechanisms for encounter disposition and resolution tracking
  • Lead Risk Adjustment Data Validation activities including audit preparations
  • Produce performance reports across risk adjustment activities and drive actionable insights
  • Coordinate with Analytics and Strategy teams to enhance program data utilization
  • Support strategic planning with risk adjustment data and program recommendations
  • Ensure compliance with CMS and state regulations
  • Develop vendor management processes and performance evaluations
  • Lead workflow re-engineering for clinical data acquisition and coding processes
  • Utilize operational improvement methodologies to enhance program outcomes
  • Develop and sustain a high-performance team to meet strategic objectives

Benefits

  • Competitive benefits and compensation package offered by Molina Healthcare
Full Job Description
Job Description

JOB DESCRIPTION Job Summary

Provides executive level strategy and leadership for the operational integrity and regulatory compliance of the organization's risk adjustment operations across all lines of business, including Medicare Advantage, Medicaid, and Affordable Care Act (ACA) Marketplace. Drives organizational risk adjustment policy, program standards, and performance, and maintains close partnerships with senior leaders across Clinical Operations, Analytics, Strategy, Technology, Encounters, Legal, and Compliance.

Essential Job Duties
  • Provides executive oversight of all risk adjustment programs across Medicare Advantage, Medicaid, and ACA Marketplace lines of business, ensuring alignment of operational activities with organizational objectives and regulatory requirements. Supporting programs across the enterprise including interaction at the state plan level.
  • Leads end-to-end program management for chart review initiatives, in-home assessments (IHA), provider clinical programs, and supplemental data efforts across all applicable lines of business.
  • Serves as the primary internal interface for the organization's IHA capability, coordinating between internal teams and external IHA vendors engaged for supplemental capacity.
  • Manages provider-facing clinical programs, including in-office assessments, ensuring program design and execution are consistent with documentation and coding standards.
  • Establishes, maintains, and enforces enterprise-wide coding standards and Clinical Documentation Improvement (CDI) protocols applicable across all lines of business.
  • Oversees coding quality evaluation processes, ensuring accuracy, consistency, and compliance with Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Category (HCC) methodology, Medicaid risk adjustment guidelines, and ACA Marketplace risk adjustment requirements as applicable.
  • Owns and governs the end-to-end data flow from coding vendor output through internal quality assurance review to encounter staging, maintaining clear accountability at each stage of the process.
  • Partners with the Encounters team to ensure the timely, accurate, and compliant submission of encounter records, including both additions and deletions, across all applicable lines of business.
  • Designs and maintains tracking and reporting mechanisms to confirm encounter disposition, identify submission gaps, and drive resolution of outstanding items.
  • Establishes escalation pathways and control processes to minimize encounter submission risk and ensure regulatory deadlines are met.
  • Leads the coordination of all Risk Adjustment Data Validation (RADV) activities, including internal audit preparation, response management to CMS audit requests, and analysis of audit findings.
  • Develops and implements strategies to improve RADV performance, reduce audit exposure, and strengthen documentation standards over time.
  • Produces and maintains comprehensive performance reporting across all risk adjustment program activities, including coding results, encounter submission rates, HCC documentation outcomes, and performance against budget expectations.
  • Coordinates with Analytics and Strategy teams to translate program data into actionable insights, opportunity identification, and prioritized improvement initiatives.
  • Supports the organization's strategic planning processes with risk adjustment performance data, forecasting inputs, and program recommendations.
  • Ensures all programs operate in full compliance with CMS regulations, state Medicaid risk adjustment guidance, and ACA Marketplace risk adjustment rules.
  • Interfaces proactively with the internal Compliance function to surface program risks, policy gaps, and emerging regulatory changes requiring operational response.
  • Leads cross-functional policy development efforts and serve as the authoritative internal voice on risk adjustment regulatory requirements and standards.
  • Owns the full vendor management lifecycle for all risk adjustment vendors, including IHA overflow providers, coding vendors, and chart retrieval partners. Establishes vendor service level agreements, performance scorecards, and governance structures to ensure quality, accountability, and value delivery.
  • Conducts regular vendor performance reviews and drives continuous improvement through structured feedback, remediation planning, and, where appropriate, contract renegotiation or vendor transition.
  • Leads re-engineering efforts for key workflows including clinical data acquisition, chart retrieval, coding quality review, and encounter submission pipelines.
  • Applies structured operational improvement methodologies to eliminate process gaps, reduce rework, and improve program outcomes across lines of business.
  • Develops and sustains a high-performance team, dedicated to best-in-class solutions; responsible for attracting, developing, and retaining top-tier talent to support strategy and long-term business objectives.

Required Qualifications
  • At least 12 years of progressive experience in risk adjustment within a managed care or health plan environment, with direct accountability for program performance, or equivalent combination of relevant education and experience.
  • At least 7 years of management/leadership experience.
  • Demonstrated experience managing risk adjustment programs across multiple lines of business, including Medicare Advantage; Medicaid and Marketplace experience strongly preferred.
  • Comprehensive knowledge of Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment methodology, Medicaid risk adjustment frameworks, Marketplace risk adjustment program requirements, and Risk Adjustment Data Validation (RADV) audit processes.
  • Experience overseeing clinical data acquisition operations, chart review programs, and in-home or in-office assessment programs.
  • Proven ability to lead multi-vendor ecosystems and cross-functional programs in a complex, matrixed organizational environment.
  • Strong analytical acumen with demonstrated capability to interpret risk adjustment performance data, identify trends, and drive data-informed decision making.
  • Proven ability to collaborate and drive/influence large-scale organizational change and initiatives with internal/external stakeholders, including providers.
  • Experience developing and enforcing risk adjustment policies, coding standards, and compliance frameworks.
  • Excellent communication and influencing skills; proven ability to engage and align senior stakeholders across clinical, operational, and administrative functions.
  • Microsoft Office suite and applicable software programs proficiency, and ability to learn new information systems and software programs.


To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package.

About Molina Healthcare

Molina Healthcare focuses exclusively on government-sponsored health care programs for families and individuals who qualify for government-sponsored health care. It contracts with state governments and serves as a health plan, providing a wide range of quality health care services to families and individuals.

Molina Healthcare Careers

Join the dedicated team at Molina Healthcare, a leader in providing quality healthcare services to families and individuals who qualify for government-sponsored programs, including Medicaid and Medicare. As one of the most respected companies in the health services industry, Molina Healthcare offers unparalleled job opportunities aimed at empowering your career growth and professional development.

Work You’ll Do

At Molina Healthcare, you will engage in meaningful work that directly impacts lives across the country. Our team is committed to innovation in healthcare, ensuring that all members receive the best care possible. By joining us, you will collaborate with skilled professionals dedicated to our mission of providing accessible, high-quality healthcare.

Career Opportunities and Growth

Whether you are looking for your first job, seeking a leadership role, or aiming to specialize in healthcare professions, Molina Healthcare offers a range of career paths. Our job opportunities span across various functions, including clinical services, customer support, IT, project management, and more. We believe in fostering the growth of our employees through professional development, leadership training, and diversity initiatives.

Internship Programs

Kickstart your career with a Molina Healthcare internship. Our internships provide invaluable workplace experience, offering a glimpse into the healthcare industry through hands-on projects and mentorship. Interns at Molina Healthcare gain critical skills that prepare them for future employment, making them competitive candidates in the job market.

Culture and Benefits

Molina Healthcare is not just a company; it’s a community. We prioritize a culture of inclusivity and respect, where all team members are encouraged to bring their whole selves to work. Our employees enjoy comprehensive benefits, including health insurance, retirement plans, and wellness programs, all designed to support both their professional and personal lives.

Join Our Team

Explore the various positions available at Molina Healthcare and find where your skills and interests align with our needs. We are continuously hiring talented individuals who are passionate about making a difference in healthcare. Prepare your resume, sharpen your interview skills, and become part of a team that values hard work and creativity.

Stay Connected

Keep up to date with the latest at Molina Healthcare: - **Career Growth and Networking:** Advance your career through our professional development and networking opportunities. Learn from leaders and peers alike to build connections that propel your career forward. - **Innovation and Leadership:** Drive change and lead with confidence by participating in our leadership and innovation training programs.

Apply Now

Ready to take the next step in your healthcare career? Search open positions that match your skills and interests on the Molina Healthcare Jobs portal. We look for driven, curious, and compassionate team players ready to make an impact.

Stay Informed

Subscribe to Molina Healthcare job alerts and receive updates on new openings and company news directly to your inbox. Tailor your subscription to match your career preferences and stay ahead in the dynamic field of healthcare. Join Molina Healthcare, where your career is nurtured, your contributions are valued, and your growth is guaranteed.
Learn more about Molina Healthcare
Size
14,000 employees
Market Cap
$19.5 billion
Industry
Healthcare
Net Income
$673 million
Founded
1980
5 Year Trend
+9.3%
Revenue
$19.4 billion
NASDAQ
MOH
* Ladders Estimates

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