Director Risk Adjustment

Role Overview

The Director of Retrospective Risk Adjustment and Audit is a key leader within the organization who utilizes strong analytical skills and expert knowledge of risk adjustment programs to ensure the accuracy of CMS risk payments and identifies opportunities for process improvement. Responsible for the oversight and execution of retrospective risk adjustment programs and audit readiness. This roles ensures accurate risk scores capture, regulatory compliance, and audit readiness.

Work Arrangement

• This is a remote position within the United States

Responsibilities

• Lead retrospective risk adjustment programs and audits
• Manages the internal Risk Adjustment Coding Team
• Ensures the accuracy and timeliness of risk adjustment submission and payment data
• Coordinates with and maintains oversight of multiple vendors and internal partners to ensure risk adjustment programs meet quality and compliance standards
• Creates new KPI and risk score trending dashboards
• Works with operational staff to ensure proper trainings, error correction procedure guidelines, and key metrics are met
• Presents to leadership on key project milestones
• Develops project plans, sets performance goals, and creates strategic roadmaps for the advancement of risk programs and initiatives
• Demonstrates a strong financial acumen and knowledge of Medicare, Medicaid, and ACA risk adjustment
• Leads RADV audits
• Collaborate with leadership in key areas to develop, provider education strategy, prioritizing enhancements, reporting needs, and provider impact analysis
• Incorporates strong process controls and compliance monitoring standards for risk adjustment activities
• Build, maintain, and train a team by establishing clear direction, responsibilities, and goals
• Remain current with risk adjustment industry and developments
• Negotiate risk adjustment statement of works and assist with RFP process
• Manages the Enrollment Team

Essential Functions

• Direct audit preparedness and execution.
• Develop and maintain retrospective programs and audits workflows, documentation, and reporting
• Partner with Compliance and Legal team to ensure regulatory adherence
• Manage relationships with retrospective and audit vendors

Education/Experience

• Bachelor’s Degree and/or equivalent work experience
• Risk Adjustment coding certification is highly desired

Other Skills

• Strategic leadership and executive communication
• Regulatory and audit expertise
• Data-driven decision making
• Experience using claims, encounter, and clinical data

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.