Health Net · 17 hours ago
Director, Risk Adjustment
Illinois, United States
Full-time
Onsite
Mid Level
$118K/yr - $219K/yr
2+ years expHealth Net is transforming the health of communities, impacting 28 million members. The Director, Risk Adjustment will lead strategic initiatives to improve risk adjustment processes, ensuring data accuracy and compliance with CMS and HHS regulations while driving financial performance.
Financial ServicesHealth CareHealth InsuranceInsurancePersonal HealthWellness
Responsibilities
Partner with executive leadership to plan the strategic direction of Risk Adjustment initiatives to facilitate achievement of the business goals and objectives and success criteria for the future. Evaluate and oversee the development and implementation of CMS and HHS risk adjustment program changes. Incorporate changes and requirements into strategy
Coordinate with appropriate functional areas including Medical Management, Quality, Pharmacy, Operations, etc. as it relates to Risk Adjustment, Clinical Risk Groups and Quality initiatives. Use analytics to define Risk Adjustment focus. Identify areas to increase quality and maximize opportunities
Direct the development of key analytics and data to support Risk Adjustment financial forecasts, analysis and reporting to engage key stakeholders and communicate program results to the organization. Educate internal and external stakeholders on changes in regons and the critical nature of risk adjustment and recommend areas of process improvement
Maximize return on investment in Risk Adjustment operations by reducing reliance on vendors and increasing validity of data submissions
Maintain and oversee an effective and optimal Risk Adjustment submission process and Quality Assurance Program. Monitor, measure and communicate Risk Adjustment performance and submission quality relative to the various program strategies
Develop performance targets for both internal and external constituents. Ensure that performance targets are set and included in contracts where appropriate. Track progress against stated goals and drive to attainment
Verify that data submissions are complete and accurate and that the pertinent authority has confirmed receipt. Serve as the subject matter expert in projects and initiatives. Drive Risk Adjustment best-practices across all lines of business
Ensure alignment and attainment of Risk Adjustment goals with business owners. Develop and implement employee training and provider outreach programs, as needed, to improve Risk Adjustment performance
Qualification
Required
Must possess a Bachelor's Degree from an accredited college or university
Position requires at least two years of experience with Risk Adjustment
Experience at a Manager or Director level is preferred
Experience with actuarial, finance and/or operational activities of a health plan
Demonstrated success in improving Risk Adjustment measures
Demonstrated success leading cross-functional teams
Ability to prioritize tasks with competing deadlines
Preferred
Preferred field of study business, math, finance, economics, actuarial science, healthcare administration or other related health care field
Benefits
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
A flexible approach to work with remote, hybrid, field or office work schedules
Company
Health Net
Health Net provides health care coverage across California to over 3 million members, regardless of stage of life and socioeconomic status.
1001-5000 employees
Funding
Current Stage
Public CompanyTotal Funding
unknown2016-03-24Acquired
1991-06-21IPO
Leadership Team
Brian Ternan
President & Chief Executive Officer
Jessica Sellner, MBA
Plan Chief Financial Officer
Recent News
Morningstar.com
2025-11-27
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