Director, Risk Adjustment Prospective Operations & Risk Mitigation

Corewell Health
United States, Michigan, Grand Rapids
Jul 22, 2025
Job Summary The Director Risk Adjustment Prospective Operations & Risk Mitigation is the thought leader role responsible for ensuring the complete and accurate documentation of Priority Health members' disease burden. This role is a key strategic leader who initiates, develops and executes/implements the multi-product risk adjustment strategy set by the executive leaders of Risk Adjustment ensuring accurate diagnosis risk coding and achieving related revenue targets. The role is responsible for helping to achieve the risk adjustment program vision, strategies, objectives, and goals. This includes monitoring targets; leading teams in analyzing, reporting, and forecasting key risk adjustment metrics; managing risk adjustment vendors; as well as, ensuring new legislation and regulations regarding risk adjustment are properly understood and addressed accordingly with policies and procedures. As such, this position will be responsible for program integrity relating to coding & documentation and will oversee the team responsible for mitigating risks and will implement the necessary procedures to ensure compliance with regulatory standards. This position will develop and manage key performance indicators (KPIs), structure processes for automation and foster a culture of accountability and efficiency. This leader will be responsible for building out core health plan-based risk adjustment operations, as well as developing innovative provider-based programs/solutions and other product-specific risk adjustment strategies as applicable. Success will require competence in risk adjustment strategy, an ability to build and scale risk adjustment programs and an ability to partner effectively with provider groups to design and implement point of care risk adjustment interventions. This position will evaluate and assess the organization's risk related to risk adjustment coding and conduct internal audits to improve compliance. Additionally, the leader will be responsible for oversight of external regulatory audits including IPM, RADV and OIG audits. This position will manage risk adjustment Prospective and Risk Mitigation team members and related functions, including all provider education efforts, all vendors related to Prospective Operations including but not limited to in-home health assessments and provider point of care (POC) solutions as well as oversight for the Enterprise Disease Burden program with the Corewell Health delivery system. In addition, the position will oversee the operations for Risk Mitigation, ensuring the appropriate metrics are established to ensure productivity and quality outcomes while conducting internal audits for both vendors and providers. Plays a key role in supporting strategic initiatives and operations to drive improvements, efficiencies, and effectiveness. The leader will need to engage executive level stakeholders to define a system strategy for risk adjustment, including strategies for provider engagement, compliance and IT system capabilities. Strategy, planning and end-to-end oversight will be necessary in this role to meet program goals. The position will be responsible for creating and developing initiatives to meet program goals including but not limited to provider incentive programs, audit and compliance processes and well as EMR optimization and other technology solutions. Lastly, the role supports the VP of Risk Adjustment in identifying, developing, promoting and executing process improvement strategies and priorities to reduce redundancies, ensure maximum efficiencies, align with other Priority Health systems and processes, as well as to ensure appropriate policies and procedures exist. Ensures alignment with the four functional area objectives: 1. To increase provider engagement to completely and accurately document the members disease burden at the point of care. 2. To partner with provider offices to obtain the right medical records at the right time and accurately document member disease burden after the point of care. 3. Mitigate risk by identifying opportunities in the medical record for improvement and education. 4. To completely and accurately submit encounter data to CMS for the mandated risk adjustment programs. Essential Functions Responsible for managing large scale, current and multi-year plan strategy development in a dynamic and evolving environment that can produce a high stress environment at times. Provide leadership planning, project coordination and management for the development of a cost-effective department while concurrently facilitating efficient operations to meet current and future business needs within the organization. Oversee data driven performance management of processes, programs, vendors, staff and providers. Conduct operations in a planned, metric-driven approach. Continuously improve end to end operations/process. Responsible to identify risk areas within existing Risk Adjustment programs and operations and execute contingency plans with all involved key stakeholders to ensure compliance with regulatory standards. Accountable for ensuring ongoing key performance indicators (KPIs) measure productivity, quality and overall impact of the company's risk adjustment program, including reporting KPIs on a weekly/monthly/quarterly/annual basis. Assists leadership in maintaining risk adjustment performance management reporting & dashboards. Effectively track and monitor programs. Partner with clinical and financial analytics teams to define opportunities and areas of focus to optimize risk adjustment performance across all products. Must be able to effectively communicate across all levels and present to large audiences including to providers, executives and others while conveying current performance against goals and objectives. Develop member and provider engagement strategies, including the use of value-based payments, incentives and other levers to encourage proactive risk management. Additionally, manage the incentive distribution to providers. Responsible for provider and office staff orientations and continued education of existing providers to ensure risk programs and initiatives are being effectively communicated. Travels to physician practices and regional offices on a per needed basis. Participate in after hours calls as necessary. Expert on risk adjustment models; maintains current view of risk adjustment regulatory changes and product-specific risk model changes; ensures appropriate operational responses to regulatory and risk adjustment program changes. Serve as subject matter expert and resource in clinical documentation and coding. Lead and collaborate in the development of coding and risk adjustment tools/training aides for contracted providers and staff. Responsible for documenting workflow process, standard operating policies and procedures and establishing robust monitoring programs that ensures performance metrics are achieved in compliance with CMS regulations, mitigating our risk adjustment exposure/risk. Contributes to and approves Priority Health Risk Adjustment Coding Guidelines. Serve as point person for relationships with health plan partners, including contracting and revenue management elements of risk arrangements as well as partner oversight of ongoing performance with providers. Provider site engagement and partnership; Partner with provider account teams to communicate risk adjustment strategies and initiatives to provider groups via JOCs and other meetings; partner with provider groups to implement risk adjustment initiatives through the Prospective team members via provider education, chart audit, etc. Internal stakeholder management: ensures open communication and collaboration cross all relevant internal departments/positions that intersect with risk adjustment (Quality, Provider Relations, Product teams, etc.). Works collaboratively with other RA leaders to assist other teams as necessary with chart retrieval and coding efforts. Assists other RA leaders with root cause analysis, provides feedback and shares findings on the analysis to leaders. Accountable for all vendor relationships related to the Prospective operations & Risk Mitigation areas including but not limited to in-home health assessments, provider solutions such as point of care (POC) tools and technology and other provider workflow technology as well as auditing vendors. Oversees all aspects of vendor process, end-to-end. Administrative: Ensure team members have appropriate skills sets related to their individual roles and assess performance issues and coach/mentor for improvement. Participate in development of annual departmental budget, monitor budget and identify budget discrepancies. Research cause and make recommendations. Communicate Risk Adjustment program to internal & external audiences so they understand program objectives, goals, benefits, risks, regulations, requirements for risk adjustment. Responsible for the development of actionable training materials, onboarding materials, reporting metrics, including scorecards for both internal and external stakeholders. Qualifications Required Bachelor's Degree or equivalent in field of study requiring consistent demonstration of communication, interpersonal, leadership and analytical skills, such as finance, accounting or business management or related field. Preferred Master's Degree in a related field of study. 10 years of relevant experience in health care related field including experience in a leadership role with direct reports. Required 7 years of relevant experience in Risk Adjustment in a health plan or medical group setting managing operations/processes and defining workflows. Required 5 years of relevant experience in a leadership role with a demonstrated ability to lead teams and manage budgets. Required Physician Practice Management and/or clinical experience. Preferred Experience implementing risk adjustments programs for Medicare Advantage or ACA products. Preferred LIC-Registered Nurse (RN) Upon Hire required Or LIC-License Practical Nursing (LPN) Upon Hire required And CRT-Professional Coder - AAPC American Academy of Professional Coders 180 Days required Or CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association 180 Days required And CRT-At least one License and/or Certification in area of specialty - UNKNOWN Unknown CRC, AAPC Certified Risk Adjustment Coder preferred Physical Demands Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs Waist to Waist > 5 lbs: Seldom up to 10 lbs Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs Waist to Overhead > 5 lbs: Seldom up to 10 lbs Bilateral Carry > 5 lbs: Seldom up to 10 lbs Unilateral Carry > 5 lbs: Seldom up to 10 lbs Pushing Force > 5 lbs: Seldom up to 10 lbs Pulling Force > 5 lbs: Seldom up to 10 lbs Sitting: Frequently Standing: Occasionally Walking: Occasionally Forward Bend - Standing: Seldom Forward Bend - Sitting: Occasionally Trunk Rotation - Standing: Seldom Trunk Rotation - Sitting: Occasionally Reach - Above Shoulder: Seldom Reach - at Shoulder or Below: Seldom Handling: Occasionally Forceful Grip > 5 lbs: Seldom Forceful Pinch > 2 lbs: Seldom Finger/Hand Dexterity: Frequently How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here. On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Priority Health - 1231 E Beltline - Grand Rapids Department Name Risk Adjustment Executive Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 40 Days Worked Monday - Friday Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.