Director of Risk Adjustment Analytics

The Director of Risk Adjustment Analytics is a strategic leadership role responsible for setting the vision and ensuring the operational excellence of all risk adjustment-related analytics for the Revenue Analytics team. This Director will serve as the primary enterprise subject matter expert, driving the financial performance and strategic direction of value-based contracts. This role requires exceptional expertise in translating complex regulatory and data requirements into actionable strategies that directly impact revenue accuracy, compliance, and overall Medical Loss Ratio (MLR).

Strategic Leadership & Core Responsibilities

This role is accountable for the strategic and operational success of the Risk Adjustment Analytics function.

• Strategic Leadership: Provide strategic direction and management for the IKC Risk Adjustment Accuracy program, ensuring alignment with organizational financial goals and compliance standards.

• Executive Reporting & Financial Impact: Design, create, and maintain executive-level reports on IKC revenue financials, accurately estimating and forecasting the financial impact of IKC initiatives on the Medical Loss Ratio (MLR) and overall contract performance.

• Data Strategy & Execution: Oversee and personally write advanced SQL queries against clinical operations and medical claims data warehouses. This ensures the delivery of deep, validated insights necessary for both operational improvement and executive decision-making.

• Compliance & Policy Oversight: Monitor evolving CMS regulations and policies to proactively adjust all risk adjustment processes, submission systems, and reporting to maintain strict compliance and prepare for audits.

• Cross-Functional Partnership: Lead collaboration efforts with clinical, financial, operational, legal, compliance, and IT teams to implement data-driven strategies that optimize risk adjustment documentation and coding accuracy.

• Subject Matter Expertise: Serve as the definitive subject matter expert on CMS risk adjustment for the entire enterprise, driving knowledge transfer and staying current on the latest industry models and trends.

Required Qualifications & Experience

Must-Haves (Key Leadership & Knowledge Requirements)

• Expert-Level CMS-HCC Mastery: Expert-level knowledge of CMS-HCC models V24 and V28, including the claims data lifecycle, submission systems (RAPS/Encounter), regulation, compliance, and audits related to risk adjustment.

• Leadership & Management: Experience developing and managing direct reports and leading analytical teams.

• Value-Based Care Proficiency: Strong understanding of healthcare economics, population health, and value-based care models.

• Executive Communication: Comfortable presenting complex analysis and insights to executive audiences, with proven ability to translate technical findings into clear business implications.

• Strategic Acumen: Demonstrated intellectual curiosity, strategic thinking, and strong project management skills with a strong entrepreneurial mindset to drive independent improvement.

Experience (Minimum Years Required)

• 3+ years of professional experience with healthcare data, specifically medical claims and/or encounter data using advanced SQL.

• 3+ years of experience in healthcare financial management, healthcare consulting, medical economics, population health, or similar experience that includes a focus on revenue cycle or value-based payment models.

• At least 1 year of experience in the creation, implementation, and rigorous impact estimation of prospective and retrospective risk adjustment initiatives.

Education

• Bachelor's or Master's Degree preferred in a quantitative, business, or health policy field, or equivalent experience acquired through accomplishments reflecting the strategic level of this position.