Director, Risk Adjustment Prospective Programs

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Vice President, Risk Adjustment, the Director of Risk Adjustment Prospective Programs is a strategic leader responsible for implementing, operationalizing, and optimizing the health plan's point-of-care, concurrent, and forward-looking risk adjustment initiatives. Unlike traditional retrospective "chart chasing," this role focuses entirely on prospective interventions, capturing accurate member health acuity before or during a provider encounter. This position executes the enterprise strategy and converts it into scalable workflows, controls, KPIs, EHR integrations, and provider-facing tools that reduce friction for independent clinicians and delegated IPAs. The primary mandate of this position is to ensure the plan's risk adjustment program is a proactive, clinically driven model. Operating within a network structure comprised of independent, Fee-for-Service (FFS) practices and delegated Independent Physician Associations (IPAs), this Director leads programs such as in-home and virtual assessments, pre-visit suspecting, point-of-care documentation supports, and concurrent validation. This leader ensures chronic conditions are documented accurately to CMS compliance standards in real time, driving revenue accuracy and improving proactive clinical care management. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salaryState of the art fitness center on-siteMedical Insurance with Dental and VisionLife, short-term, and long-term disability optionsCareer advancement opportunities and professional developmentWellness programs that promote a healthy work-life balanceFlexible Spending Account – Health Care/ChildcareCalPERS retirement457(b) option with a contribution matchPaid life insurance for employeesPet care insurance Education & Requirement A minimum of eight (8) years of progressive experience in healthcare managed care or risk adjustment operations, with a distinct, heavy emphasis on executing prospective (point-of-care, in-home, or concurrent) programs. At least five (5) years of leadership and management experience leading teams, projects, initiatives, and/or cross-functional groups. Demonstrated success improving compliant documentation capture, provider adoption, and submission integrity through EHR integrations and analytics driven suspectingBachelor’s degree in nursing, public health, healthcare administration or a related field from an accredited institution requiredMaster’s degree in nursing, public health, healthcare administration or a related field from an accredited institution preferredCertified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC) from AAPC or AHIMA requiredCDI certification (e.g., ACDIS CCDS) or comparable documentation improvement credential preferredPossession of an active, unrestricted, and unencumbered Registered Nurse (RN) or Nurse Practitioner (NP) license issued by the California BRN preferred Key Qualifications Must have a valid California Driver’s licenseComprehensive knowledge and in-depth understanding of:Launching healthcare operations or behavioral change campaigns within a non-employed, independent FFS provider networkProspective risk adjustment platforms, EHR alert integrations (Epic, Athena, eClinicalWorks, etc.)Managing large-scale national prospective/IHA vendors (e.g., Signify, Matrix, Optum)Program management, change management, and stakeholder facilitation for provider audiences. Vendor management (SLAs, ROI, data security) and budget stewardshipProspective risk adjustment concepts and operations; documentation standards (ICD 10 CM/HCC, MEAT), HIPAA/privacy; RADV readiness principlesEncounter/EDPS submission mechanics and downstream data quality controlsExceptional communicator capable of convincing fiercely independent, time crunched FFS providers to adopt prospective tools into their daily workflowsData literacy (Excel/BI tools) to monitor KPIs and communicate insights clearlyAbility to balance prospective/concurrent capture with compliance and audit readinessIntermediate–advanced skills in using analytics tools (e.g., Excel, BI tools)Strong presentation and facilitation skills for varied clinical audiencesAdvanced ability to:Build immediate peer-to-peer credibility with network physiciansModel change leadership, clear communication, and cross‑functional collaborationMaintain strong professional relationships with providers, internal stakeholders, and external partnersAct as a credible advocate for prospective documentation excellence, while ensuring alignment with company policies and strategiesPrioritize resources using network tieringDrive measurable outcomes while maintaining strong provider relationships Start your journey towards a thriving future with IEHP and apply TODAY! Pay Range $154,128.00 USD Annually - $204,214.40 USD Annually