Director, Risk Adjustment

Join PacificSource and help our members access quality, affordable care!

• →Establish and maintain the enterprise risk adjustment strategy, governance, and control framework—defining performance measures, operating cadence, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs.
• →Develop and implement scalable prospective programs engagement and education programs dedicated to driving continuous quality improvement in documentation and diagnosis reporting, with transparent feedback loops and measurable objectives in value-based care
• →Support member engagement strategies to strengthen engagement and wrap around services aligned with improved health outcomes.
• →Oversee risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education, while collaborating with the Population Health Director to design annual education strategies and foster partnerships anchored in quality and value.
• →Oversee end to end Medicare Advantage risk adjustment submissions (including EDS) and support ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation integrity, provider engagement, and full compliance with official coding guidelines and program requirements.
• →Lead the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and IT on data reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure robust data lineage, operational insights, and audit readiness.
• →Ensure audit readiness and response for internal and external audits (MA and HHS RADV), overseeing documentation standards, medical record retrieval controls, coding validation, CMS/IVA submissions, CMS feedback and appeals, error trending, root cause analysis, and CAPA development.
• →Lead the Risk Adjustment Coding function and core operational workflows—including medical record retrieval, retrospective and prospective coding/validation, and adherence to official coding guidelines—while identifying and mitigating compliance, financial, and operational risks related to coding discrepancies through strong controls and monitoring.
• →Lead people management activities for all risk adjustment roles, including hiring, coaching, performance and productivity management, competency development, and succession planning; ensure the team remains engaged, knowledgeable about CMS and regulatory changes, and equipped with skills that meet or exceed industry standards.
• →Direct departmental budgeting and vendor oversight by managing annual budgets, monitoring variances, and implementing corrective actions; lead vendor selection, contracting, and performance management to ensure compliance, privacy/security standards, and effective knowledge transfer, partnering with Population Health and Clinical Quality to align investments and maximize value across programs.
• →Build strong cross department partnerships by collaborating with Finance, Medicare Operations, Network Management, Provider Contracting, Health Services, IT, Actuarial & Underwriting, Compliance, and other internal teams to coordinate business activities and support organizational alignment.

• →Contribute to strategic initiatives by participating in internal committees and leadership meetings, representing organizational priorities, sharing information across teams, and supporting the annual Medicare Bid process through strong analytical and financial capabilities.
• →Serve as an active member of managerial forums, promoting collaboration, sharing insights, and helping drive operational execution across departments.
• →Meet department and company performance and attendance expectations.
• →Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• →Perform other duties as assigned.

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.