Director of Risk Adjustment

2 weeks ago


Fort Lauderdale, United States Holy Cross Health Fl Full time

Job Description

**Must live in the South Florida area - this is not a remote position**


Roles and Responsibilities

  • Oversee, coordinate, or perform data mining and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine annual risk adjustment program strategies to achieve optimal performance. Incorporate data-driven analysis into the risk adjustment processes.
  • Develop and monitor metrics of program success.
  • Oversight of vendor relationships to drive program success (analytics, practice management).
  • Oversight of client contractual requirements and deliverables.
  • Development and monitoring of provider scheduling and prioritization.
  • Identification and development of training opportunities to drive success.
  • Identification and development of process improvement.
  • Measurement and presentation of financial impact to executive leadership.
  • Working across matrixed organization to drive results.
  • Establishes operating policies and procedures for all risk adjustment programs and processes in coordination with internal and external operational units.
  • Represent the organization in dealing with vendors, delegated entities, providers and the Centers for Medicare and Medicaid Services (CMS).
  • Determining resource needs to support incremental functionality required for government products; contributes to budget, and acquires resources accordingly.
  • Develops and maintains relationships with key medical leaders


Education & Qualifications

  • South Florida area candidates or candidates willing to relocate
  • Bachelor’s degree from a four-year college required
  • RHIA/RHIT required credentials preferred
  • Specialization in building business units to become more effective and efficient while fostering a team environment
  • 7+ years’ experience working in a value-based provider group, health plan, and/or vendor contracting with health plans providing annual wellness/risk adjustment services
  • 5+ years’ experience in a leadership role in a capacity developing and implementing risk adjustment, coding, wellness assessment, and analytics programs and processes
  • Expertise in Medicare programs and regulations including fraud and abuse and Medicare Hierarchical Condition Coding Risk Adjustment
  • Excellent analysis and presentation skills
  • Experience working in high-growth environment preferred
  • Valid driver’s license



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