Head of Risk Adjustment/Coding Operations

Key Responsibilities

• Define and execute the enterprise risk adjustment strategy in partnership with cross-functional leaders, ensuring alignment with organizational objectives, payer requirements, and regulatory standards.
• Design and oversee risk adjustment programs that balance retrospective and prospective approaches, informed by performance data, operational feasibility, and provider experience.
• Lead coding operations, including staffing models, workflows, training, quality assurance, and performance management, with a focus on consistency and scalability.
• Establish performance metrics, reporting, and feedback mechanisms that connect risk adjustment activity to outcomes and value, and inform ongoing prioritization.
• Partner with Clinical and Market leaders to support effective, right-sized provider education and engagement related to documentation and coding.
• Collaborate with Data and Technology teams to leverage analytics, automation, and tools that improve efficiency and decision-making across the risk adjustment lifecycle.
• Develop and mentor the risk coding team, fostering accountability and continuous improvement.
• Ensure compliance with CMS regulations, coding guidelines, and documentation standards, maintaining strong audit readiness and risk controls.

2026 Priorities

• Evaluate and implement a best-in-class NLP solution to maximize efficiency in our coding programs.
• Develop and maximize our Coding Education Platform to provide a tiered solution for our provider partners.
• Partner with all signed health plans to establish a retrospective review process, inclusive of chart retrieval, chart review, and provider education.
• Implement ASM Prospective solutions to capture value from our day-to-day coding process and reduce the administrative burden of chart collection at End Of Year.
• Establish solutions to align chart collection to enhance our efficiency and remove administrative impact.
• Develop clear reporting and governance to monitor impact, guide prioritization, and support ongoing optimization of risk adjustment efforts.

About You

• Bachelor’s degree in healthcare administration, public health, business administration, or related field.
• CRC, CPC, CPMA, or equivalent certifications.
• 10+ years experience in Medicare Advantage risk adjustment, with deep expertise in HCC coding, RAF methodologies, and CMS requirements.
• 7+ years of experience leading certified coding teams with accountability for performance outcomes.
• Demonstrated experience evolving risk adjustment programs in dynamic or growing organizations.
• Working knowledge of V28 rules and regulations and applications.
• Excellent leadership, communication, and interpersonal skills, with the ability to collaborate effectively with cross-functional teams.
• Comfortable in ambiguous, fast-paced roles with a focus on change management and continuous improvement (Start-Up experience a plus).