Overview
You can get further details about the nature of this opening, and what is expected from applicants, by reading the below. Job Title:
Director of Risk Adjustment and Quality
Department:
Risk Adjustment & Quality Product Operations
Reports to:
VP of Product
The Director of Risk Adjustment and Quality leads the strategy, execution, and optimization of risk adjustment and quality initiatives for our SaaS platform serving Medicare Advantage, provider organizations, and payer markets. This role ensures our platform delivers accurate risk scoring, quality measure tracking, and regulatory compliance while supporting clients’ value-based care and financial performance goals.
Key Responsibilities
Own the risk adjustment and quality product roadmap for Medicare Advantage, provider organizations, and commercial payer clients.
Lead the development of HCC coding, suspecting, recapture tracking, and gap closure modules within the platform.
Oversee analytics, reporting, and client enablement programs focused on risk adjustment accuracy and quality measure performance (HEDIS, STAR Ratings, CAHPS, etc.).
Ensure compliance with CMS guidelines, NCQA standards, and other regulatory requirements specific to Medicare Advantage and commercial risk programs.
Partner with Product, Engineering, and Data Science teams to deliver scalable, high-performing SaaS solutions supporting MA plans, provider groups, and health plans.
Work directly with client leadership teams to translate regulatory and business requirements into actionable platform configurations and reporting strategies.
Provide subject matter expertise on CMS file formats (BCDA, CCLF, EDGE) and value-based care models including ACO REACH, MSSP, and commercial risk arrangements.
Lead internal teams including clinical coders, quality analysts, and client success staff focused on risk and quality performance improvement.
Analyze and report on key KPIs including RAF score accuracy, gap closure rates, and STAR metric performance, driving continuous improvement strategies.
Monitor industry trends, regulatory updates, and competitor activity to inform product and business strategy.
Qualifications
Bachelor’s degree in Healthcare Administration, Public Health, Data Science, or a related field; Master’s preferred.
8+ years of experience in Medicare Advantage, risk adjustment, and quality improvement within a payer, provider, or SaaS environment.
Proven leadership experience overseeing risk adjustment and quality programs, including team management and cross-functional collaboration.
Deep understanding of Medicare Advantage program requirements, including HCC coding, STAR ratings, HEDIS measures, CAHPS, and VBP models.
Experience with payer-provider collaboration and managing risk programs across different organizational structures.
Familiarity with healthcare data formats: FHIR, HL7, BCDA, CCLF, EDGE files, and claims data.
Exceptional communication, client-facing, and presentation skills.
Preferred Skills
Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC).
Experience deploying AI or machine learning solutions for risk adjustment or quality gap closure.
Strong understanding of data integration workflows supporting payers, providers, and Medicare Advantage plans.
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You can get further details about the nature of this opening, and what is expected from applicants, by reading the below. Job Title:
Director of Risk Adjustment and Quality
Department:
Risk Adjustment & Quality Product Operations
Reports to:
VP of Product
The Director of Risk Adjustment and Quality leads the strategy, execution, and optimization of risk adjustment and quality initiatives for our SaaS platform serving Medicare Advantage, provider organizations, and payer markets. This role ensures our platform delivers accurate risk scoring, quality measure tracking, and regulatory compliance while supporting clients’ value-based care and financial performance goals.
Key Responsibilities
Own the risk adjustment and quality product roadmap for Medicare Advantage, provider organizations, and commercial payer clients.
Lead the development of HCC coding, suspecting, recapture tracking, and gap closure modules within the platform.
Oversee analytics, reporting, and client enablement programs focused on risk adjustment accuracy and quality measure performance (HEDIS, STAR Ratings, CAHPS, etc.).
Ensure compliance with CMS guidelines, NCQA standards, and other regulatory requirements specific to Medicare Advantage and commercial risk programs.
Partner with Product, Engineering, and Data Science teams to deliver scalable, high-performing SaaS solutions supporting MA plans, provider groups, and health plans.
Work directly with client leadership teams to translate regulatory and business requirements into actionable platform configurations and reporting strategies.
Provide subject matter expertise on CMS file formats (BCDA, CCLF, EDGE) and value-based care models including ACO REACH, MSSP, and commercial risk arrangements.
Lead internal teams including clinical coders, quality analysts, and client success staff focused on risk and quality performance improvement.
Analyze and report on key KPIs including RAF score accuracy, gap closure rates, and STAR metric performance, driving continuous improvement strategies.
Monitor industry trends, regulatory updates, and competitor activity to inform product and business strategy.
Qualifications
Bachelor’s degree in Healthcare Administration, Public Health, Data Science, or a related field; Master’s preferred.
8+ years of experience in Medicare Advantage, risk adjustment, and quality improvement within a payer, provider, or SaaS environment.
Proven leadership experience overseeing risk adjustment and quality programs, including team management and cross-functional collaboration.
Deep understanding of Medicare Advantage program requirements, including HCC coding, STAR ratings, HEDIS measures, CAHPS, and VBP models.
Experience with payer-provider collaboration and managing risk programs across different organizational structures.
Familiarity with healthcare data formats: FHIR, HL7, BCDA, CCLF, EDGE files, and claims data.
Exceptional communication, client-facing, and presentation skills.
Preferred Skills
Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC).
Experience deploying AI or machine learning solutions for risk adjustment or quality gap closure.
Strong understanding of data integration workflows supporting payers, providers, and Medicare Advantage plans.
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