Director, Medicare Risk Adjustment

Ultimate Health Plans is seeking a strategic and results-driven Director, Medicare Risk Adjustment to lead and optimize its Medicare Advantage Risk Adjustment program. This leadership role is responsible for developing and executing strategies that improve risk adjustment accuracy, financial performance, provider engagement, and regulatory compliance across the provider network.

The ideal candidate will have extensive Medicare Advantage experience, deep knowledge of CMS Risk Adjustment methodologies, and a proven ability to lead cross-functional teams while driving measurable performance outcomes.

Key responsibilities

• Lead the overall Medicare Risk Adjustment strategy to maximize program performance and financial outcomes.
• Develop and implement initiatives that improve risk score accuracy, documentation quality, and coding compliance.
• Monitor, analyze, and report on Medicare Advantage performance metrics and financial results.
• Identify opportunities for improvement and implement action plans to achieve organizational goals.
• Serve as the primary point of contact for participating providers, physician groups, and Independent Practice Associations regarding risk adjustment performance.
• Conduct provider meetings and deliver education focused on documentation improvement, coding accuracy, and CMS compliance.
• Develop targeted provider education programs based on coding trends, audit results, and performance data.
• Foster strong relationships with providers and key stakeholders to support achievement of risk adjustment objectives.
• Ensure compliance with CMS Risk Adjustment regulations and guidelines.
• Partner with Risk Coding teams to validate diagnosis capture and accurate submission within CMS timelines.
• Audit provider documentation and ICD-10 coding practices to ensure compliance with CMS Risk Adjustment requirements.
• Lead coding audit activities, including RADV audits and corrective action initiatives.
• Oversee remediation efforts and resubmissions for failed CMS submissions when necessary.
• Protect the confidentiality of member information and maintain HIPAA compliance.
• Collaborate with Quality, Compliance, Coding, Performance, and Clinical teams to achieve organizational objectives.
• Lead cross-functional projects and workgroups to support risk adjustment and Medicare Advantage performance goals.
• Identify operational efficiencies and implement process improvements.
• Manage timelines, deliverables, risks, and stakeholder communications across multiple initiatives.