Operations Vice President, Risk Adjustment

Vice President, Risk Adjustment

Job Summary:

The Vice President, Risk Adjustment is a key senior level leader responsible for the strategic design, implementation and oversight of the organization's risk adjustment program. This individual ensures accurate, compliant and optimized risk capture processes to support revenue integrity and population health strategies in Medicare Advantage. The ideal candidate brings deep expertise in CMS-HCC risk adjustment, clinical documentation improvement and has proven ability to lead high performing teams in a matrixed environment. Collaborate with other departments including finance, medical economics, market and executive leadership, revenue cycle and other key stakeholders.

Duties and Responsibilities:

• Develop and execute enterprise-wide risk adjustment strategy to align with regulatory requirements and financial objectives
• Oversee all aspects of risk adjustment including data analytics, coding accuracy, clinical documentation improvement strategy and vendor management
• Lead cross functional teams including coding, analytics, compliance, medical economics and operations to ensure seamless integration of risk adjustment initiatives
• Monitor and ensure compliance with CMS, health plans, and state specific regulations and audit requirements
• Lead end-to-end timely and accurate submission of risk adjustment data to CMS including overseeing the reconciliation of CMS MAO-004 reports to validate submission accuracy
• Translate risk adjustment performance into actionable insights to support medical management and quality initiatives
• Drive innovation and efficiency in risk capture methodologies
• Partner with finance, actuarial, operations teams to forecast, track performance and manage risk score impacts for all contracted products
• Collaborate with Chief Clinical Officer on provider education needs to ensure documentation and coding accuracy
• Evaluate and manage relationships with third party vendors providing risk adjustment services
• Serve as internal subject matter expert on all aspects of risk adjustment policy changes and risk scoring methodologies
• Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities
• Promote a culture of accountability, innovation and compliance

Required Skills/Abilities:

• Expert level knowledge of CMS-HCC models V24 and V28, claims data lifecycle and submission systems
• Excellent communication, executive presence and relationship building skills
• Strong operational knowledge of coding standards (ICD-10, HCC) and clinical documentation

• Experience working with large payer networks and risk adjustment third party vendors
• Strategic thinker with excellent analytical, critical thinking, problem-solving, interpersonal, and relationship building skills.

Minimum Qualifications:

• Bachelor's degree in healthcare administration, accounting, finance, or related field; Master's degree MBA, MHA, MPH preferred
• 10+ years of experience in risk adjustment, Medicare Advantage or related healthcare operations
• Strong understanding of healthcare economics, population health and value-based care frameworks

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  • Embodies and serves as a role model of ArchWell Health's Values:
  • Be compassionate
  • Strive for excellence
  • Earn trust
  • Show respect
  • Stay resilient
  • Always do the right thing
  
  
  
  

About ArchWell Health:

At ArchWell Health, we're creating a community of caring designed to help our members stay healthy and engaged. By focusing on a strong provider-patient relationship, routine wellness, and staying active, our members enjoy a higher level of care and better quality of life after the age of 60. Everything we do is for seniors. We believe seniors should be heard, listened to, and given ample time by their physicians to live well later in life.

Our value-based care model is designed to prevent illnesses while keeping members healthy and happy in every aspect of their life. We deliver best-in-class primary care at comfortable, accessible neighborhood centers where older adults can feel at home and become part of a vibrant, wellness-focused community. We're passionate about caring for older adults and united by the belief that caring has the power to change everything for our members.

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.