Risk Adjustment Strategy Director

Employment Type

: Full-Time


: Financial Services - Insurance

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The Risk Adjustment Strategy Director leads the development of risk adjustment strategies and the development of risk adjustment analytics for all risk adjustment programs, products to meet business and client performance expectations.

  • Lead risk adjustment business strategy by applying in-depth knowledge of Commercial and Medicare Advantage risk score calculation, payment methodologies and compliance requirements.
  • Formulate risk adjustment strategies the achieve business and client objectives in a compliant manner.
  • Develop business cases to support risk adjustment program and produce continuous improvement and enhance long term strategic performance.
  • Define and coordinate analytics to identify benchmarks and risk adjustment continuous improvement opportunities and formulate new ideas for risk adjustment programs, processes and products in support of performance objectives.
  • Define analytics to measure the performance of Risk Adjustment programs, processes and products, and formulate standard and ad hoc analyses for management and clients as appropriate.
  • Evaluate CMS policies and Call Letters to support timely updates to risk adjustment strategies and to advise clients.
  • Facilitate and enable coordination and collaboration across quality and care management programs for efficiency and enhanced performance.
  • Analyze and recommend potential partner relationships for risk adjustment strategies.
  • Run pilots to test new programs.
  • Provide expertise, knowledge and guidance to clients and management relative to risk adjustment performance and strategies
  • Provide expertise and guidance with respect to the regulations, competitors and the industry at large with respective to risk adjustment performance and strategies.
  • Develop and deliver demonstrations and presentations to clients, provider organizations, physicians and internal stakeholders related to risk adjustment products, programs and processes.
  • Provide expert technical leadership to highly visible, sensitive and multi-faceted analytic projects and products.
  • Direct initiatives related to strategy implementation and ensure achievement and solid documentation of all key deliverables and due dates.

Performs other related duties which may not be specifically listed in the position description, but which are within the general occupational series and responsibility level typically associated with the employee's class of work.



Bachelor's degree in business administration, finance, healthcare administration or related field required. Master's degree in healthcare, business administration, or related field preferred. Continuous learning, as defined by the company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.


Ten (10) years of experience in risk adjustment including leadership experience implementing new risk adjustment programs from Medicare Advantage or Medicaid products. Experience and knowledge in risk score data analytics.

  • Knowledge of Center of Medicare & Medicaid Services (CMS) rules and regulations related to the Medicare and Medicaid and Affordable Care Act commercial risk adjustment programs.
  • Knowledge of Medicare Advantage and commercial risk adjustment methodologies, operating requirements and processes, compliance expectations, risk identification and risk mitigation programs.
  • Knowledge of federal laws and regulations governing federal business programs.
  • Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
  • Ability to effectively present information and respond to questions from groups of managers, and clients
  • Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.
  • Ability to formulate large scale, current and multi-year plan for strategy development in a dynamic and evolving environment.
  • Ability to conduct operations in a planned, metric-driven approach.
  • Excellent knowledge of software packages including Excel, Access and large data software such as SQL.


Work is performed in an office setting with no unusual hazards. Travel is required.

The qualifications listed above are intended to represent the minimal skills and experience levels associated with performing the duties and responsibilities contained in this position description. The qualifications should not be viewed as absolute standards, but as general guidelines that should be considered with other position-related criteria.

We are an Equal Opportunity Employer. Diversity is valued, and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.

Associated topics: actuarial, actuarial analyst, actuarial director, assistant actuary, associate actuary, director actuary, investment actuary, retirement actuary, risk, statistics

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