CommunityCare ยท 4 hours ago
Director Risk Adjustment
Tulsa, OK
Full-time
Onsite
Senior Level, Lead/Staff
10+ years expCommunityCare is focused on enhancing healthcare delivery, and they are seeking a Director of Risk Adjustment to lead their risk adjustment program for ACA and Medicare Advantage businesses. This role involves strategic design, implementation, and oversight of risk adjustment initiatives, ensuring compliance and maximizing efficiency in data reporting and provider education.
Health CareHealth Insurance
Hiring Manager
Megan McMurphy
Responsibilities
Develop and execute enterprise-wide risk adjustment strategy to align with regulatory requirements and financial objectives
Oversee all aspects of risk adjustment data analytics, including CMS reporting, clinical documentation improvement strategy, and vendor management
Lead cross functional teams including coding, analytics, compliance, medical economics and operations to ensure seamless integration of risk adjustment initiatives
Monitor and ensure compliance with CMS, Oklahoma regulations, and audit requirements
Lead end-to-end timely and accurate submission of risk adjustment data to CMS including overseeing the reconciliation of CMS reports to validate submission accuracy
Translate risk adjustment performance into actionable insights to support medical management and quality initiatives
Drive innovation and efficiency in risk capture methodologies
Partner with finance, actuarial, operations teams to forecast, track performance and manage risk score impacts for all contracted products
Collaborate with Clinical Operations on provider education needs to ensure documentation and coding accuracy
Evaluate and manage relationships with third party vendors providing risk adjustment services
Serve as internal subject matter expert on all aspects of risk adjustment policy changes and risk scoring methodologies
Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities
Promote a culture of accountability, innovation and compliance
Performs other job-related duties as assigned
Qualification
Required
Expert level knowledge of Medicare Advantage and ACA Risk Adjustment reporting lifecycle and submission systems
Possesses an insatiable need for process improvement and operational effectiveness
Excellent communication, executive presence and relationship building skills
Strategic thinker with excellent analytical, critical thinking, problem-solving, interpersonal, and relationship building skills
Successful completion of Health Care Sanctions background check
Bachelor's degree in healthcare administration, data science, accounting, finance, or related field
10+ years of experience in risk adjustment, Medicare Advantage or related healthcare operations
6 plus years of management experience
Preferred
Master's degree MBA, MHA, MPH
Company
CommunityCare
CommunityCare is dedicated to providing high-quality, cost-effective health care management services in the communities it serves.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Rusty Wyrick
Senior Vice President, Chief Technology and Transformation officer
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