The ED, Strategic Planning and Oversight, Risk Adjustment is responsible for overseeing daily RA operations across all function's areas (Retrospective Chart Operations, Prospective Operations, Reporting & Analytics and Provider Engagements. This role and team serve as a connection point across the organization and enterprise functions related to Risk Adjustment. As the Executive Director of the RA program, this role will report directly to the SVP of Risk Adjustment. The individual will also be responsible for overseeing initiatives and activities across all RA processes and for streamlining processes, plans, and organizational communication across RA sub-teams.

This role will oversee the delivery of al l Risk Adjustment programs and connections to business areas including Quality, Population Health, Clinical Operations, Revenue Integrity, Revenue Cycle, Compliance and Regulatory. Responsible for achieving Risk Adjustment program outcomes including business goals across departments, functions or regions. Oversees the program team, holding the team and team members accountable for results and guides the decisions of others regarding internal and / or external resource requests. Proactively monitors, identifies and mitigates risks, issues and trigger events within and across multiple interdependent programs by leveraging expertise and implementing changes. Oversees compliance of program activities by ensuring program plans and team members adhere to relevant policies and procedures. Oversees the alignment, buy-in, engagement and support of diverse program stakeholders. Champions the standards for vendor performance, provides direction for service improvements, and directs partnerships and contract negotiations with vendors.

• Lead teams that will deliver coding guidelines and standards across the enterprise, delivery planning and process improvement functions across the Risk Adjustment teams and provide regulatory policy and risk management resourcing for the enterprise related to Risk Adjustment.


• End to End Program Management:
  
  
  
  • Oversees daily RA activities, and the operation of multiple units, ensuring timelines, regulatory requirements, and operational goals are being met.
  
  
  
  


• Cross-team Collaboration:
  
  
  
  • Resolves barriers and facilitates communications between teams to ensure each role is aligned on the expectations for their respective tasks and the team meets all regulatory deadlines
  
  
  
  


• Strategy Development and Regulatory Monitoring:
  
  
  
  • Monitor all CMS and market-specific requirements to ensure compliance with federal and state regulations and leverage changes in regulatory requirements to inform future state RA strategy.
  
  
  
  


• Executive Communications and Alignment:
  
  
  
  • Communicate with senior leadership across all RA sub teams and ensure teams are aligned on program goals, execution timelines, and delegation of responsibilities.
  
  
  
  


• Program Execution Support:
  
  
  
  • Communicates with senior leadership on the key details of projects and programs to drive deliverables to effective execution
  
  
  
  


• Tracking and Reporting:
  
  
  
  • Tracks year over year process improvement through collaboration with reporting and analytics teams and drives initiatives to increase program accuracy and quality.
  
  
  • Also responsible for setting standardized status monitoring templates across RA sub-teams.
  
  
  
  


• Risk Mitigation:
  
  
  
  • Anticipates and removes obstacles that impact performance; work with health plans and vendors to mitigate any risks or escalated issues
  
  
  
  


• Risk Adjustment Perspective:
  
  
  
  • Acts as a thought leader on industry trends, benchmarks, and best practices; shares best practices within and across teams to drive improvement.
  
  
  
  

• Minimum eight (8) years of program management experience in risk adjustment within a large health plan with a proven record of leading teams to success.

• BA in Healthcare Administration, Health Policy, Business, or a related field

• N/A

• Leadership and Project Management:
  
  
  
  • Demonstrated ability to lead end-to-end risk adjustment operations, effectively managing timelines, resources, and stakeholders.
  
  
  • Proven track record in driving complex projects to successful completion.
  
  
  
  


• Communication Skills and Executive Presence:
  
  
  
  • Superior communication skills, essential for frequent interactions across all RA operational teams, adjacent team leaders in care and quality management, vendors, providers, and other relevant stakeholders.
  
  
  • Ability to convey complex information clearly and persuasively.
  
  
  
  


• Regulatory Knowledge:
  
  
  
  • In-depth familiarity with various value-based care programs, Lines of Business (LoBs), and comprehensive knowledge of regulatory and compliance standards across different markets, including Medicare, Medicare Advantage, Affordable Care Act (ACA) Marketplace, Commercial plans and Medicaid.
  
  
  
  


• Strategy Development:
  
  
  
  • Experience in formulating and executing risk adjustment policies and strategies that drive organizational success and ensure regulatory compliance.
  
  
  • Experience in forecasting, operational planning, and strategy development
  
  
  
  

• Advanced degrees or relevant certifications are advantageous.