Medica · 1 month ago
Senior Director Risk Adjustment
United States
Full-time
Remote
Director/Executive
$150K/yr - $257K/yr
12+ years expMedica is a nonprofit health plan serving communities in multiple states. The Senior Director of Risk Adjustment is responsible for leading the design and continuous improvement of the operating model across HEDIS and Risk Adjustment, ensuring effective data management and compliance while collaborating with various internal and external teams.
HealthcareHealth CareMedical
No H1B
Responsibilities
Provide integrated leadership across HEDIS and Risk Adjustment to ensure the full lifecycle—from data intake and processing through encounter management, submission, reconciliation, and audit—is standardized, controlled, and continuously improved
Ensure program execution operates as a coordinated system with clear ownership, predictable outcomes, and scalable practices across all lines of business
Drive sustained improvements in data collection, processing, and validation, including claims to encounter logic, submission controls, reconciliation routines, and audit traceability
Partners with Technology, Data, and Analytics teams to strengthen upstream controls, reduce rework, and increase confidence in performance and financial outputs
Establish and maintain governance structures that ensure regulatory compliance, audit readiness, and defensible outcomes across HEDIS and Risk Adjustment
Oversee preparation and response for HEDIS audits, RADV, IVA, and related regulatory reviews, ensuring issues are identified early and addressed through durable solutions
Own the end to end vendor operating model for Risk Adjustment and related support services
Define scope, performance expectations, handoffs, and escalation paths, and ensure vendor contributions are fully integrated into Medica’s operating model and performance standards
Serve as the primary integrator across Quality, Performance Outcomes, Technology, Data, Analytics, Finance, Actuarial, Provider Quality, and external partners
Align priorities, timelines, and resources to ensure coordinated execution and reduce operational friction across complex dependencies
Protect enterprise outcomes by stabilizing execution, improving predictability, and reducing regulatory, financial, and reputational risk
Enable senior leadership to focus on strategy and long term organizational maturity by ensuring day to day system performance is well governed and proactively managed
Promote a positive work environment, sets an atmosphere of open communication and feedback
Serve as a leader within the division and to the organization, working to ensure collaboration and teamwork across all teams to achieve objectives
Ensure alignment with and effective execution of strategies to achieve team key performance indicators as well as Medica’s overall objectives
Foster a highly productive and collaborative team environment that effectively utilizes the skills and talents of team members
Qualification
Required
Bachelor's degree or equivalent experience in related field; Advanced degree preferred
12+ years of experience in healthcare performance, quality, or regulatory programs
At least 8–10 years of direct experience in Risk Adjustment across Medicare Advantage, Medicaid, and/or ACA/IFB
Demonstrated senior‑level leadership experience with accountability for Risk Adjustment data workflows, including claims and supplemental data intake, encounter creation and submission, reconciliation, and audit readiness (RADV, IVA, or equivalent)
Demonstrated understanding of the financial impacts of Risk Adjustment and quality performance, including how data integrity, encounter accuracy, and submission outcomes influence base rates, bids, forecasts, and regulatory exposure across lines of business
Working experience with HEDIS and quality measurement programs, including submission cycles, audit support, and integration with broader enterprise performance and regulatory strategies
Strong understanding of claims‑to‑encounter logic, data validation, and the financial implications of Risk Adjustment accuracy on bids, forecasts, and regulatory posture
Proven ability to lead complex, cross‑functional initiatives spanning Technology, Data, Analytics, Finance, Actuarial, Operations, Providers, and external vendors
Demonstrated capability to operate at both strategic and system levels, translating enterprise priorities into coordinated execution and sustained performance improvement
Preferred
Experience working with CMS, NCQA, and state regulatory frameworks
Strong understanding of claims‑based data, encounter processing, and performance measurement
Experience managing and integrating vended services within an enterprise operating model
Demonstrated success partnering with Technology, Data, Analytics, Finance, and Actuarial teams
Executive‑level communication skills and comfort operating in ambiguity
Benefits
Incentive plan compensation in addition to base salary
Competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees
Company
Medica
Medica is a company that provides health coverage to meet customers needs for health plan.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Naylor
President and CEO
Jeni Alm
Vice President, Provider Partnerships and Solutions
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