Risk Adjustment Director

About the role

The Alliance is seeking a Risk Adjustment Director to lead the Risk Adjustment Department. This role can be located in one of the Alliance's service counties (Mariposa, Merced, Monterey, Santa Cruz, or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire.

Responsibilities

• Provide strategic management oversight in designing, implementing, directing, and monitoring the Alliance’s Risk Adjustment Department functions
• Direct the Risk Adjustment Department, act as a subject matter expert, and provide executive-level advice and guidance on coding and risk adjustment methodologies and overall business operations
• Direct, manage, and supervise Risk Adjustment Department staff

Requirements

• A motivated and seasoned leader in the managed care industry, with expertise in risk adjustments
• Excellent communication skills, with strength in building relationships and partnering with cross-functional teams
• Champion accountability across the organization
• Experience in overseeing the Medicare Risk Adjustment life cycle
• Strong data and analytical skills, including SQL, dashboarding, and reporting
• Be invested in staff development and empowering teams to do their best work
• Medi-Cal experience is a plus
• IPA/Medical Group experience highly desired

Qualifications

• Knowledge of:
• The managed care industry and of Medicare health insurance payment methodologies
• Medicare (Hierarchical Condition Categories) risk adjustment models
• Methods and techniques of developing and delivering data management strategies that support contract analysis, trend management, budgeting, forecasting, strategic planning, and healthcare operations
• Principles and practices of provider reimbursement methodologies, pricing, and fee schedules for all provider types, including hospital, physician, and ancillary providers
• Healthcare industry specific terms and healthcare related data types and structures, including member, claims, clinical, and provider types
• Methods and techniques of valuating for physician and inpatient and outpatient hospital costs

Skills

• Demonstrate strong analytical skills, accurately collect, manage, and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk
• Perform complex analysis related to rate negotiations, health care cost reports, and determination of rates for hospitals, clinics, long-term care facilities, allied health services, professional services, and specialist services
• Develop, plan, organize, and direct finance programs and activities that are complex in nature and regional in scope
• Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
• Demonstrate a collaborative management style, build rapport, demonstrate excellent public relations skills, and effectively manage internal and external business relationships

Benefits

• Medical, Dental and Vision Plans
• Amble Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• RoBust Health and Wellness Program
• Onsite EV Charging Stations

Pay

Zone 1 Pay Range: $210,000 - $250,000
Zone 2 Pay Range: $200,000 - $235,000

Schedule

Hybrid work environment with remote interviews via Microsoft Teams. In-office or in-community presence may be required for some positions and is dependent on business need.