Location: Huntington Beach, CA (5 days a week in office)
Description:Vice President of Risk Adjustment is an executive-level position responsible for the strategic integration of revenue integrity and clinical outcomes. This leader oversees the complete lifecycle of risk capture, including prospective, concurrent, and retrospective workflows, while ensuring high performance in quality metrics such as CMS Star Ratings and HEDIS.
What You Will Do:- Develop and execute the enterprise-wide Medicare Advantage risk adjustment strategy aligned with organizational goals and CMS requirements.
- Serve as a subject matter expert on CMS-HCC models, risk score forecasting, and regulatory changes impacting Medicare Advantage.
- Partner with executive leadership to integrate risk adjustment into broader financial, clinical, and population health strategies.
- Oversee all risk adjustment activities including prospective and retrospective programs, provider coding initiatives, chart reviews, in-home assessments, and data submissions.
- Ensure accurate, timely, and compliant submission of encounter and diagnosis data to CMS.
- Ensure full compliance with CMS regulations, RADV, OIG guidance, and internal compliance standards.
- Lead internal and external audit responses, including RADV and other CMS or regulatory audits.
- Partner closely with Compliance, Legal, and Internal Audit to mitigate risk and ensure program integrity.
- Lead efforts to improve year-over-year risk score performance while maintaining strong compliance and audit readiness.
- Collaborate with network management and clinical leadership to drive provider education, documentation improvement, and adoption of best practices.
- Support value-based care arrangements by aligning risk adjustment processes with quality and care management initiatives.
- Guide clinical documentation improvement (CDI) programs and physician engagement strategies.
You Will Be Successful If:- Strategic and analytical mindset with strong financial acumen
- Executive-level communication and influence
- Collaborative leadership across clinical and non-clinical teams
- High integrity and commitment to compliance
- Ability to operate effectively in a fast-paced, highly regulated environment
What You Will Bring:- Master's degree in Business (MBA), Health Administration (MHA), or a related clinical field.
- A minimum of 10 years of progressive leadership in managed care, with specialized expertise in Medicare Advantage and Value-Based Care frameworks.
- Deep understanding of ICD-10 coding standards, HCC methodologies, and CMS quality reporting requirements.
- Certifications (Preferred): Certified Professional in Health Quality (CPHQ), Certified HEDIS Compliance Auditor (CHCA), or a clinical license (RN)
