VP, Risk Adjustment & Quality

Overview

We are seeking a VP, Risk Adjustment & Quality to take ownership of the strategic integration between revenue integrity and clinical outcomes. In this role, you will oversee the complete lifecycle of risk capture including prospective, concurrent, and retrospective workflows while ensuring our organization maintains high performance in CMS Star Ratings and HEDIS quality metrics.

• Strategic Execution: Develop and execute enterprise-wide Medicare Advantage risk adjustment strategies aligned with CMS requirements.
• SME Leadership: Serve as the subject matter expert on CMS-HCC models, risk score forecasting, and regulatory shifts.
• Operations Oversight: Manage all risk adjustment activities, including provider coding initiatives, chart reviews, in-home assessments, and data submissions.
• Compliance & Audit: Ensure full compliance with CMS, RADV, and OIG guidance. Lead internal and external audit responses.
• Performance Excellence: Drive year-over-year risk score performance while maintaining strict audit readiness.
• Cross-Functional Collaboration: Partner with network management and clinical leadership to improve documentation (CDI) and physician engagement.

• Education: Master’s degree in Business (MBA), Health Administration (MHA), or a related clinical field.
• Experience: 10+ years of progressive leadership in managed care, with specialized expertise in Medicare Advantage and Value-Based Care frameworks.
• Technical Knowledge: Deep understanding of ICD-10 coding standards, HCC methodologies, and CMS quality reporting.
• Certifications (Preferred): CPHQ (Quality), CHCA (HEDIS Auditor), or a clinical license (RN).

• You have a strategic and analytical mindset with strong financial acumen.
• You are an expert at executive-level communication and influencing cross-functional teams.
• You operate effectively in fast-paced, highly regulated environments.
• You maintain high integrity and a relentless commitment to compliance.

• Work Environment: This is a 100% onsite opportunity in Huntington Beach, CA
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• Requirement: Candidates must be local and comfortable being in the office 5 days a week, or be fully prepared to relocate immediately.