AVP, Medicare Risk Adjustment Performance
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Job Description
Executive leading enterprise Medicare risk adjustment strategy and RAF performance for Alignment Health, a senior-focused healthcare company. Overseeing providers, coding, analytics, vendors, finance, and RADV readiness.
Responsibilities:
- Provide executive leadership for Alignment's enterprise Risk Adjustment performance strategy and operations
- Lead development and execution of prospective, concurrent, and retrospective Risk Adjustment strategies
- Drive provider and market execution and achieve annual RAF performance objectives
- Oversee provider engagement, coding operations, chart retrieval, submission, analytics, vendor management, and revenue realization
- Partner with Market Operations, Network Management, Clinical Operations, Finance, Compliance, and Data & Technology teams
- Lead the annual operating plan, including goals, measures, milestones, resources and market-level execution plans
- Establish and monitor performance guidelines for quality, productivity, service levels and financial outcomes
- Use analytics, reporting and strategic business analysis to identify opportunities, risks, root causes and interventions
- Partner with Finance and Actuarial teams on forecasting, revenue implications, bid development and long-range planning
- Establish strategic direction and performance expectations for Risk Adjustment vendors and external partners
- Serve as executive sponsor for provider coding performance and documentation improvement initiatives
- Develop scalable reporting, analytical and operational capabilities supporting visibility, audit readiness and reduced manual controls
- Partner with DTS and enterprise analytics teams on data strategy and reporting capabilities
- Define requirements for workflow modernization, automation, provider enablement and enterprise reporting
- Sponsor technology initiatives improving scalability, productivity, transparency and audit readiness
- Support RADV readiness, validation findings, reconciliation, diagnosis corrections and audit remediation
- Establish policies, procedures, standard work and governance routines for accurate and compliant execution
- Maintain knowledge of CMS requirements, model changes and regulatory guidance and translate changes into operational plans
- Communicate complex operational, technical and financial information as executive insights and business narratives
- Build, mentor and retain a high-performing multidisciplinary team
- Develop multi-year strategies, annual goals, KPIs and resource requirements
- Lead business cases for investments, operational initiatives and technology capabilities
- Oversee assigned leaders and staff, including workforce planning, recruiting, training, goal-setting, performance management and coaching
- Perform other duties as assigned
Requirements:
- Ten or more years of progressive experience in managed care, Medicare Advantage, healthcare analytics, healthcare finance, risk adjustment, population health or related operations
- Experience leading enterprise Risk Adjustment programs across multiple markets and provider arrangements
- Demonstrated responsibility for financial performance, forecasting, strategic planning, or major business initiatives
- Proven track record managing executive stakeholders and enterprise-wide programs
- Seven or more years of people leadership, including development of high-performing analytical or operational teams
- Bachelor’s degree in healthcare, business, finance, analytics, information systems or a related field, or equivalent relevant experience
- Demonstrated knowledge of CMS-HCC risk adjustment methodology, Medicare Advantage reimbursement, coding and documentation programs, encounter data, and performance measurement
- Demonstrated experience designing or leading analytics, reporting, data governance or scalable data infrastructure that supports reporting accuracy, regulatory compliance and audit readiness
- Experience leading complex cross-functional initiatives and working with executives, providers, vendors, compliance partners and technical teams
- Experience with risk adjustment forecasting, provider performance analytics, data warehousing, SQL-based analytics or business intelligence platforms
- Experience supporting multiple government-program lines of business or large, multi-market Medicare Advantage operations
- Advanced ability to translate complex data into executive-level insights, recommendations and action plans
- Strong verbal, written, presentation, organization and relationship-management skills
- Must be efficient in Excel; SQL knowledge preferred
- Good organization skills
- Good analytical skills
- Good interpersonal skills
- Strong communication skills
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