Principal, Risk Adjustment

About the role

The Principal, Risk Adjustment, is a director-level strategic leader responsible for cross-functional collaboration to drive enterprise risk adjustment performance, supporting new market acquisition and expansion, and leading high-impact, scalable program initiatives from concept through execution. This role provides leadership across risk adjustment strategy, trend management, provider engagement, operational execution, compliance, vendor oversight & technology enablement. The role will drive cost saving measures, improve operational efficiencies, and increase provider engagement and regulatory compliance.

Essential Functions

Strategic Leadership & Market Expansion

• Lead risk adjustment strategy for new market acquisition, expansion, and operational readiness.
• Assess market-specific risk adjustment opportunities, operational gaps, provider capabilities, and technology requirements.
• Develop & execute scalable risk adjustment playbooks for new & existing markets.
• Partner with executive leadership & cross-functional stakeholders to align risk adjustment strategies with enterprise growth, revenue integrity, quality & value-based care objectives.
• Ensures department policies, programs, and plans are consistent with and support Priority health's core values and mission.

Program Development & Execution

• Lead risk adjustment initiatives from ideation & business case development through implementation, monitoring & continuous improvement.
• Define program objectives, success metrics, timelines, resource needs, risks, and operational dependencies.
• Oversee & support implementation of prospective, concurrent & retrospective risk adjustment programs.
• Drive process standardization across markets and vendors.
• Monitor initiative performance & develop corrective action plans to close gaps in execution or outcomes.

Trend Management & Performance Oversight

• Lead trend management for all risk adjustment initiatives, including development, implementation, monitoring, reporting, and optimization.
• Analyze trends and financial impacts and make recommendations for gap closure.
• Partner with Analytics & Actuary teams to forecast performance, identify improvement opportunities, and quantify revenue impact.
• Develop executive-level reporting & dashboards to track performance against targets.
• Identify emerging risks, market variation, provider performance issues, data gaps, and operational barriers impacting risk adjustment outcomes.

Provider Engagement & Technical Enablement

• Lead implementation of provider-facing technical applications and workflows that support risk adjustment accuracy and documentation improvement.
• Partner with IDA/DS, Analytics, Clinical Operations, and external vendors and providers to integrate risk adjustment tools into EMR/EHR platforms and provider workflows.
• Ensure provider facing tools are scalable across markets.
• Collaborate with Provider Network and external providers to support adoption, training, workflow redesign and performance accountability.

Operational Governance & Compliance

• Establish governance, controls, and monitoring processes for risk adjustment initiatives & technology-enabled workflows.
• Ensure risk adjustment activities comply with CMS requirements, coding guidelines, documentation standards, HIPAA, and internal compliance policies.
• Partner with Compliance and Audit teams to support RADV readiness, internal audits, chart review governance, and remediation plans.
• Develop policies, procedures, operating models, and controls to support sustainable & compliant risk adjustment operations.

Cross-Functional Leadership

• Partner with market leadership, provider engagement, clinical operations, finance, actuarial, analytics, compliance, IDA/DS, product and vendor partners.
• Influence stakeholders across a matrixed organization to drive alignment, accountability, and execution.
• Lead steering committee updates, executive briefings, and cross-functional workgroups.
• Translate complex risk adjustment insights into actionable business strategies & operational priorities.
• Provide leadership, coaching, and direction to project teams, analysts, market partners, and operational stakeholders.

Vendor & Partner Management

• Lead and participate in evaluating, selecting and managing vendors supporting risk adjustment.
• Support defining vendor performance expectations, service-level metrics, implementation timelines, and quality standards.
• Monitor vendor outcomes, resolve issues, and ensure alignment with enterprise objectives and compliance requirements.
• Partner with procurement, legal, compliance, and finance on contracting, performance reviews, and ongoing governance.

Qualifications

• Bachelor's Degree in business, health care administration or related clinical field. Required
• Master's Degree in business, health care administration or related clinical field. Preferred
• 12 years of relevant experience
• Strong Risk Adjustment and Project Management experience with a detailed understanding of Enterprise Risk Management & Risk Adjustment for MA & ACA LOB Required
• CRT-ScrumMaster, Certified (CSM) - Required
• CRT-Lean Six Sigma Black Belt Certification (CSSBB) - Preferred
• CRT-Project Management Professional (PMP) - PMI - Preferred

Physical Demands

• Pallet to Waist (6" from floor) > 5 lbs: Seldom
• Waist to Waist > 5 lbs: Seldom
• Waist to Chest (below shoulder) > 5 lbs: Seldom
• Waist to Overhead > 5 lbs: Seldom
• Bilateral Carry > 5 lbs: Seldom
• Unilateral Carry > 5 lbs: Seldom
• Pushing Force > 5 lbs: Seldom
• Pulling Force > 5 lbs: Seldom
• Sitting: Frequently
• Standing: Occasionally
• Walking: Occasionally
• Forward Bend - Standing: Seldom
• Forward Bend - Sitting: Occasionally
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Occasionally
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Occasionally
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Finger/Hand Dexterity: Frequently

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings

Schedule

Full time, Day shift, 40 hours per week, Monday-Friday.

This response is AI-generated, for reference only.