Director, Quality Analytics - Risk Adjustment (Director II)

Join Us in this Amazing Opportunity We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. The Team You’ll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Director, Quality Analytics - Risk Adjustment (Director II) and help shape the future of healthcare where you’ll be an integral part of our Quality Analytics team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework . If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. The Director for Quality Analytics Risk Adjustment will be accountable for a cross functional operating team model for CalOptima Health’s risk adjustment program including analytics and reporting, medical record retrieval, retrospective and prospective coding and provider engagement while ensuring adherence to official regulatory guidelines and industry best practices. You'll provide strategic and tactical direction for Medicare, Medi-Cal and Covered California risk adjustment programs based on Hierarchical Condition Categories (HCC) and Chronic Illness and Disability Payment System (CDPS)-Rx risk models. Key accountabilities include program design and management, vendor oversight, provider and member outreach when applicable, and leadership of business intelligence efforts supporting Medicare Advantage, Affordable Care Act (ACA) Commercial, and Medicaid risk adjustment performance. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 40% - Leadership Functions Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department. Directs, manages and oversees the Risk Adjustment team including assigning and evaluating work, making recommendations on hiring, training and setting goals, conducting performance evaluations and recommending and implementing corrective actions up to and including termination. Oversees the creation, implementation and updates of policies and procedures, standard operating procedures, performance guarantees and workflows. Assists the Executive Director with annual staffing and budget plans and monitors resource allocation for the department. Provides regular and frequent feedback to executive leadership, committees, department leaders and stakeholders regarding the status of CalOptima Health’s risk adjustment program and outcomes. Supports member engagement strategies to strengthen engagement and wrap around services aligned with improved health outcomes. Develops comprehensive risk adjustment strategy, objectives, tactics and initiatives to drive continuous quality of care improvements, appropriate reimbursement and compliance with Centers for Medicare & Medicaid Services (CMS) and state mandates, regulations and audits. Directs and oversees Risk Adjustment functional areas driving optimal outcomes, including chart retrieval, coding, analytics/reporting and encounter data submissions. Leads the Risk Adjustment Analytic function including risk score and submission monitoring, reporting, and analytics; partner with Actuarial, Finance, and Information Technology (IT) on data reconciliation, forecasting, and scenario modeling; evaluate regulatory and payment methodology impacts; and ensure robust data lineage, operational insights, and audit readiness. Builds strong cross department partnerships by collaborating with Finance, Medicare Operations, Clinical Operations, IT, Compliance, and other internal teams to coordinate business activities and support organizational alignment. 55% - Risk Adjustment Program Oversight Establishes and maintains the enterprise risk adjustment strategy, governance, and control framework—defining performance measures, operating cadence, roles and responsibilities, and resourcing to ensure accurate, complete, and compliant data submission across programs. Develops and implements scalable prospective programs engagement and education programs dedicated to driving continuous quality improvement in documentation and diagnosis reporting, with transparent feedback loops and measurable objectives in value-based care. Oversees risk adjustment processes including provider feedback, Annual Wellness Visit insights, and Coding team education. Oversees end to end Medicare Advantage risk adjustment submissions and supports ACA EDGE Server activities, ensuring accuracy, completeness, timeliness, documentation integrity, provider engagement, and full compliance with official coding guidelines and program requirements. Contributes to oversight of risk adjustment vendors, including procurement of new vendors, monitoring of vendor Key Performance Indicators (KPIs) and adherence to contract deliverables. Provides subject matter expertise, maintains knowledge of regulatory updates and interprets applicable federal and state regulations, CMS guidelines and Medicare and ACA models. Implements a governance structure that provides oversight and audit readiness; builds statistically sound strategies to evaluate, monitor compliance and educate stakeholders of any potential risk and implement appropriate remediation activities. Analyzes and identifies risk adjustment accuracy and opportunities. Collaborates with Finance to project and monitor the impact of coding programs on revenue for forecasting and monthly financial statement accruals. Ensures the coordination of processes, protocols and data flow between Risk Adjustment and cross-functional teams, including Care Management, Quality, Behavioral Health, resulting in appropriate follow of care and quality improvement activities. 5% - Other Completes other projects and duties as assigned. Do You Have What the Role Requires? Bachelor’s degree in business administration, health management/administration, public health or related field PLUS 7 years of experience overseeing and leading Risk Adjustment programs required, preferably for Medicare, Covered California, and Medicaid risk adjustment programs; an equivalent combination of education and experience sufficient to successfully perform the essential duties. 5 years of experience working with Medicare Advantage Plans required. 5 years of progressive leadership experience, including direct supervision of staff required. You’ll Stand Out More If You Possess the Following: Master’s degree in business administration, health management/administration, public health or related field. Certified Risk Adjustment Coder Certification. What the Regulatory Agencies Need You to Possess? N/A Your Knowledge & Abilities to Bring to this Role: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem‑solve and possess project management skills. Work in a fast‑paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi‑program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and other information applicable to the position assignment. Your Physical Requirements (With or Without Accommodations): Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face‑to‑face interactions. Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. Lifting and moving objects, patients and/or equipment 10 to 25 pounds. Ways We Are Here For You You’ll enjoy competitive compensation for this role. Our current hiring range is: Pay Grade: 321 - $181,257 - $290,011 ($87.14 - $139.42). The final salary offered will be based on education, job‑related knowledge and experience, skills relevant to the role and internal equity among other factors. This position is approved for Partial Telework (If the position is Telework, it is eligible in California only) A comprehensive benefits package CalPERS pension program and additional retirement packages. Additional benefits and perks including: A generous PTO program A quality work life balance Various wellness programs Tuition Reimbursement Professional development opportunities Career development opportunities Flexible scheduling And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families. Our Work Environment: If located at the 500, 505 Building or a remote work location: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment is usually moderate. If located at PACE: Work is typically indoors in a clinical setting serving the frail and elderly. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud. If located in the Community: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. Employee will occasionally work outdoors in varied temperatures. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud. Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post‑offer pre‑employment medical examination (for specific positions). If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at View phone number on click.appcast.io if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. #J-18808-Ljbffr