CommunityCare HMO, Inc.
Reporting - Director Risk Adjustment
CommunityCare HMO, Inc., Tulsa, Oklahoma, United States, 74145
Posted Saturday, January 10, 2026 at 6:00 AM
JOB SUMMARY The Director of Risk Adjustment is responsible for the strategic design, implementation, and oversight of CCOK’s risk adjustment program for both ACA and Medicare Advantage businesses. This individual will coordinate with various areas including IT, Healthcare Economics, Finance, and the Clinical Auditing team in order to maximize the efficiency and effectiveness of Risk Adjustment strategy, analytics, and data reporting to CMS, as well as supporting processes regarding provider education and member engagement to identify opportunities for improved accuracy in coding.
KEY RESPONISBILITIES
Develop and execute enterprise-wide risk adjustment strategy to align with regulatory requirements and financial objectives
Oversee all aspects of risk adjustment data analytics, including CMS reporting, clinical documentation improvement strategy, and vendor management
Lead cross functional teams including coding, analytics, compliance, medical economics and operations to ensure seamless integration of risk adjustment initiatives
Monitor and ensure compliance with CMS, Oklahoma regulations, and audit requirements
Lead end-to-end timely and accurate submission of risk adjustment data to CMS including overseeing the reconciliation of CMS reports to validate submission accuracy
Translate risk adjustment performance into actionable insights to support medical management and quality initiatives
Drive innovation and efficiency in risk capture methodologies
Partner with finance, actuarial, operations teams to forecast, track performance and manage risk score impacts for all contracted products
Collaborate with Clinical Operations on provider education needs to ensure documentation and coding accuracy
Evaluate and manage relationships with third party vendors providing risk adjustment services
Serve as internal subject matter expert on all aspects of risk adjustment policy changes and risk scoring methodologies
Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities
Promote a culture of accountability, innovation and compliance.
Performs other job-related duties as assigned.
QUALIFICATIONS
Expert level knowledge of Medicare Advantage and ACA Risk Adjustment reporting lifecycle and submission systems
Possesses an insatiable need for process improvement and operational effectiveness
Excellent communication, executive presence and relationship building skills
Strategic thinker with excellent analytical, critical thinking, problem-solving, interpersonal, and relationship building skills.
Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE
Bachelor’s degree in healthcare administration, data science, accounting, finance, or related field; Master’s degree MBA, MHA, MPH preferred
10+ years of experience in risk adjustment, Medicare Advantage or related healthcare operations
6 plus years of management experience.
CommunityCare is an equal opportunity at-will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin
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JOB SUMMARY The Director of Risk Adjustment is responsible for the strategic design, implementation, and oversight of CCOK’s risk adjustment program for both ACA and Medicare Advantage businesses. This individual will coordinate with various areas including IT, Healthcare Economics, Finance, and the Clinical Auditing team in order to maximize the efficiency and effectiveness of Risk Adjustment strategy, analytics, and data reporting to CMS, as well as supporting processes regarding provider education and member engagement to identify opportunities for improved accuracy in coding.
KEY RESPONISBILITIES
Develop and execute enterprise-wide risk adjustment strategy to align with regulatory requirements and financial objectives
Oversee all aspects of risk adjustment data analytics, including CMS reporting, clinical documentation improvement strategy, and vendor management
Lead cross functional teams including coding, analytics, compliance, medical economics and operations to ensure seamless integration of risk adjustment initiatives
Monitor and ensure compliance with CMS, Oklahoma regulations, and audit requirements
Lead end-to-end timely and accurate submission of risk adjustment data to CMS including overseeing the reconciliation of CMS reports to validate submission accuracy
Translate risk adjustment performance into actionable insights to support medical management and quality initiatives
Drive innovation and efficiency in risk capture methodologies
Partner with finance, actuarial, operations teams to forecast, track performance and manage risk score impacts for all contracted products
Collaborate with Clinical Operations on provider education needs to ensure documentation and coding accuracy
Evaluate and manage relationships with third party vendors providing risk adjustment services
Serve as internal subject matter expert on all aspects of risk adjustment policy changes and risk scoring methodologies
Executive level reporting identifying actual to expected performance, outlier trends and prevalence opportunities
Promote a culture of accountability, innovation and compliance.
Performs other job-related duties as assigned.
QUALIFICATIONS
Expert level knowledge of Medicare Advantage and ACA Risk Adjustment reporting lifecycle and submission systems
Possesses an insatiable need for process improvement and operational effectiveness
Excellent communication, executive presence and relationship building skills
Strategic thinker with excellent analytical, critical thinking, problem-solving, interpersonal, and relationship building skills.
Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE
Bachelor’s degree in healthcare administration, data science, accounting, finance, or related field; Master’s degree MBA, MHA, MPH preferred
10+ years of experience in risk adjustment, Medicare Advantage or related healthcare operations
6 plus years of management experience.
CommunityCare is an equal opportunity at-will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin
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