Lightbeam Health Solutions
Director of Risk Adjustment and Quality
Lightbeam Health Solutions, Dallas, Texas, United States, 75215
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Director of Risk Adjustment and Quality
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Lightbeam Health Solutions Get AI-powered advice on this job and more exclusive features. Job Description
Job Description
Job Title:
Director of Risk Adjustment and Quality
Department:
Risk Adjustment & Quality Product Operations
Reports to:
VP of Product
Position Summary:
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.
Lightbeam Internal Use Only:
Position Security Classification
CRITERIA: POSITION RISK LEVEL
High
Risk (if any of these are true)
Access to
Restricted
information, including PHI and PII
Elevated access privileges
Access to the Security Infrastructure
Medium
Risk
Access to
Confidential , but not to
Restricted
information
Low
Risk
Access to
Unclassified
information only
Director of Risk Adjustment and Quality
: High
CRITERIA: SECURITY ROLES & RESPONIBILITIES
Security Roles & Responsibilities:
Approve security-related changes Execute security-related changes Not applicable
Policy/procedures for Lightbeam
Cyber Security Incident Response (CSIRT) team
Director of Risk Adjustment and Quality:
Not Applicable
SECURITY ROLE-SPECIFIC TRAINING
Annual Incident Response Exercises Seniority level
Seniority level Director Employment type
Employment type Full-time Job function
Job function Finance and Sales Industries IT Services and IT Consulting Referrals increase your chances of interviewing at Lightbeam Health Solutions by 2x Get notified about new Risk Director jobs in
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Director Quality Patient Safety and Risk
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Director of Risk Adjustment and Quality
role at
Lightbeam Health Solutions 1 day ago Be among the first 25 applicants Join to apply for the
Director of Risk Adjustment and Quality
role at
Lightbeam Health Solutions Get AI-powered advice on this job and more exclusive features. Job Description
Job Description
Job Title:
Director of Risk Adjustment and Quality
Department:
Risk Adjustment & Quality Product Operations
Reports to:
VP of Product
Position Summary:
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.
Lightbeam Internal Use Only:
Position Security Classification
CRITERIA: POSITION RISK LEVEL
High
Risk (if any of these are true)
Access to
Restricted
information, including PHI and PII
Elevated access privileges
Access to the Security Infrastructure
Medium
Risk
Access to
Confidential , but not to
Restricted
information
Low
Risk
Access to
Unclassified
information only
Director of Risk Adjustment and Quality
: High
CRITERIA: SECURITY ROLES & RESPONIBILITIES
Security Roles & Responsibilities:
Approve security-related changes Execute security-related changes Not applicable
Policy/procedures for Lightbeam
Cyber Security Incident Response (CSIRT) team
Director of Risk Adjustment and Quality:
Not Applicable
SECURITY ROLE-SPECIFIC TRAINING
Annual Incident Response Exercises Seniority level
Seniority level Director Employment type
Employment type Full-time Job function
Job function Finance and Sales Industries IT Services and IT Consulting Referrals increase your chances of interviewing at Lightbeam Health Solutions by 2x Get notified about new Risk Director jobs in
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Risk Management - Wholesale Credit Risk - Product - Data Strategy - Vice President
Irving, TX $133,365.00-$156,900.00 2 weeks ago Irving, TX $156,160.00-$234,240.00 3 days ago VP, Compl Risk Mgmt Officer - Regulatory Architecture Compliance, Product Program Management / UAT - C13 (Irving, TX)
Irving, TX $114,720.00-$172,080.00 1 day ago Irving, TX $107,200.00-$178,600.00 2 weeks ago Risk Management - Wholesale Credit - Generative AI Data Scientist, Vice President
Director Quality Patient Safety and Risk
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr