Risk Adjustment Director

We believe every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully. 

While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment. 

We have an opportunity to join the Alliance as the Risk Adjustment Director leading the Risk Adjustment Department. 

This position can be located in one of our 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. 

Reporting to the Chief Financial Officer, you will:

• 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

The Finance Division acts as the guardian of the Alliance’s financial health. We track the pulse of the organization by analyzing budgets, forecasting future performance, and navigating the ever-changing economic and political landscape.

To keep the Alliance financially strong and secure, we wear several hats and partner with every department in the organization to translate fiscal data into insights and action. From managing funds, to risk management, and compliance, we ensure the Alliance’s responsible use of public funds.

• 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

To read the full position description and list of requirements, click here. 

• 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
• Ability to:
  • 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
• Education and Experience:
  • Bachelor’s degree in Finance, Business, Healthcare Administration, Mathematics, Statistics, or a closely related field 
  • A minimum of ten years of experience in healthcare finance or analytics, which included a minimum of five years of experience with Medicare risk adjustment processes, a minimum of two years of experience related to Medicare Managed Care Programs, and a minimum of three years of supervisory experience (a Master’s degree may substitute for two years of general healthcare finance or analytics experience); or an equivalent combination of education and experience may be qualifying

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. 

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.