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Job Title:
Director of Risk Adjustment and Quality
The experience expected from applicants, as well as additional skills and qualifications needed for this job are listed below.
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 levelDirector Employment type
Employment typeFull-time Job function
Job functionFinance and Sales IndustriesHospitals and Health Care Referrals increase your chances of interviewing at CareSignal – Lightbeam's Deviceless Remote Patient Monitoring by 2x Sign in to set job alerts for “Risk Director” roles. Dallas, TX $250,000.00-$300,000.00 3 weeks ago Risk Management - Lead Credit Officer - Vice PresidentRisk Management - Asset Based Lending Credit Officer - Vice President Richardson, TX $117,100.00-$199,500.00 2 weeks ago Director, Corporate Insurance & Risk ManagementRisk Management - Credit Portfolio Insights and Analytics - Vice PresidentSenior Director Collateral Risk Policy– Condo/Co-opNon-Financial Risk – Project Management – Vice President (Dallas, TX)Risk Management - Counterparty Prime Brokerage Coverage - Vice PresidentTechnology Risk - Global Cyber Defense and Intelligence - Governance and Risk Management - Vice PresidentRisk Management - Counterparty Portfolio Analytics and Stress Testing - Vice PresidentSenior Director, Transactions Financial Due Diligence | Corporate Finance & Restructuring Dallas, TX $155,500.00-$374,000.00 5 days ago Technology Operational Risk Management Lead - Vice PresidentAML Policy and Governance Lead, Vice President Irving, TX $105,000.00-$140,000.00 2 weeks ago Director, Corporate Transactions Group - FDDRisk Management - Wholesale Credit Risk - Product - Data Strategy - Vice PresidentDirector Quality Patient Safety and RiskTechnical Director, Risk Control- Property Dallas, TX $104,000.00-$197,000.00 2 weeks ago EY-Parthenon - Strategy and Execution - Deal Management - Health - Director Dallas, TX $205,000.00-$235,000.00 1 day ago Senior Director of Regulatory Operations, 2 Hour Learning (Remote) - $400,000/year USDCorporate Director, PFS Outsourcing & Strategic Initiatives We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
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Director of Risk Adjustment and Quality
The experience expected from applicants, as well as additional skills and qualifications needed for this job are listed below.
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 levelDirector Employment type
Employment typeFull-time Job function
Job functionFinance and Sales IndustriesHospitals and Health Care Referrals increase your chances of interviewing at CareSignal – Lightbeam's Deviceless Remote Patient Monitoring by 2x Sign in to set job alerts for “Risk Director” roles. Dallas, TX $250,000.00-$300,000.00 3 weeks ago Risk Management - Lead Credit Officer - Vice PresidentRisk Management - Asset Based Lending Credit Officer - Vice President Richardson, TX $117,100.00-$199,500.00 2 weeks ago Director, Corporate Insurance & Risk ManagementRisk Management - Credit Portfolio Insights and Analytics - Vice PresidentSenior Director Collateral Risk Policy– Condo/Co-opNon-Financial Risk – Project Management – Vice President (Dallas, TX)Risk Management - Counterparty Prime Brokerage Coverage - Vice PresidentTechnology Risk - Global Cyber Defense and Intelligence - Governance and Risk Management - Vice PresidentRisk Management - Counterparty Portfolio Analytics and Stress Testing - Vice PresidentSenior Director, Transactions Financial Due Diligence | Corporate Finance & Restructuring Dallas, TX $155,500.00-$374,000.00 5 days ago Technology Operational Risk Management Lead - Vice PresidentAML Policy and Governance Lead, Vice President Irving, TX $105,000.00-$140,000.00 2 weeks ago Director, Corporate Transactions Group - FDDRisk Management - Wholesale Credit Risk - Product - Data Strategy - Vice PresidentDirector Quality Patient Safety and RiskTechnical Director, Risk Control- Property Dallas, TX $104,000.00-$197,000.00 2 weeks ago EY-Parthenon - Strategy and Execution - Deal Management - Health - Director Dallas, TX $205,000.00-$235,000.00 1 day ago Senior Director of Regulatory Operations, 2 Hour Learning (Remote) - $400,000/year USDCorporate Director, PFS Outsourcing & Strategic Initiatives 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