Director, Prospective Risk Adjustment Programs

At MVP Health Care, we're on a mission to create a healthier future for everyone - which requires innovative thinking and continuous improvement. To achieve this, we're looking for a Director, Prospective Risk Adjustment Programs to join #TeamMVP. If you have a passion for leadership, relationship-building and improving healthcare quality this is the opportunity for you.

• Growth opportunities to uplevel your career
• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
• Competitive compensation and comprehensive benefits focused on well-being
• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.

Qualifications you'll bring:

• Bachelor's degree in related field (e.g., health-related, behavioral science).
• Advanced degree and clinical experience are both a plus.
• Certifications: CPC (Certified Professional Coder), CRC (Certified Risk Adjustment Coder), Risk Adjustment Practitioner Certification (RISE) or similar certification is a plus.
• Health Educator Affiliation(s) is a plus
• Minimum of 7+ years of relevant experience with risk adjustment, quality, provider engagement and related areas in healthcare, with at least 3+ years in a leadership or director role.
• Knowledge: Strong understanding of CMS risk adjustment methodology, ICD-10 coding, clinical documentation, healthcare regulations, and payer operations.
• Excellent leadership, education and mentoring skills.
• Ability to manage complex projects and guide matrixed teams to achieve strategic goals.
• Analytical mindset with strong proficiency in data analysis and performance reporting.
• In-depth knowledge of healthcare data systems, claims, and risk adjustment-specific methodologies, coding and compliance.
• Excellent communication and interpersonal skills for cross-functional collaboration.

• 
  
  
  
  • Regulatory Understanding: knowledge of healthcare laws and regulations, including HIPAA, ACA, reimbursement models (e.g., fee-for-service, value-based care), and accreditation standards (e.g., NCQA, URAC).
  • Reimbursement Models: Familiarity with different insurance models and how providers are compensated (e.g., capitation, bundled payments, pay-for-performance).
  • Data Analysis & Performance Monitoring:
    
    
    
    • Provider Performance Metrics: ability to track and assess provider performance using objectives and key results, including risk adjustment, quality of care, patient satisfaction, claims processing, and financial performance.
    • Reporting and Insights: experience using analytics tools to generate reports that provide actionable insights for providers, helping drive decision-making and tracking improvements in provider performance.
    • Health IT and EHR Systems: Understanding of electronic health records (EHR), telemedicine platforms, and provider portals to facilitate communication and streamline administrative processes.
    
    
    
    
  • Relationship Management:
    
    
    
    • Conflict Resolution: Ability to mediate and resolve disputes between healthcare providers and the organization in a way that maintains a positive relationship.
    • Provider Engagement: Experience building and maintaining long-term partnerships with healthcare providers, demonstrating empathy, trust, and responsiveness.
    • Stakeholder Communication: Skilled in tailoring communication for different stakeholders, including senior management, providers, and external partners, to ensure clarity and alignment.
    
    
    
    
  • Problem-Solving & Critical Thinking:
    
    
    
    • Issue Resolution: Strong ability to identify, analyze, and resolve problems related to risk adjustment and related operational inefficiencies.
    • Innovative Solutions: Think creatively about solutions to challenges faced by healthcare providers.
    • Strong Communication: Ability to articulate the needs and concerns of both providers and the organization.
    
    
    
    
  
  
  
  
• Curiosity to foster innovation and pave the way for growth
• Humility to play as a team
• Commitment to being the difference for our customers in every interaction

Your key responsibilities:

• Strategic Leadership: With Risk Adjustment, Provider Partnership Liaison (PPL) and Medical Director teams, help develop and guide the organization's provider-focused risk adjustment strategy, ensuring alignment with business objectives and compliance with federal and state regulations.
• Collaboration with Clinical Teams: Work with clinical teams to ensure that clinical documentation is complete, accurate, and reflective of patient conditions to support optimal risk scores.
• Team Education: Coach, mentor, and guide a matrixed, cross-functional team involved in provider partnership development, risk adjustment, and quality improvement.
• Regulatory Compliance: Ensure compliance with all regulatory requirements related to risk adjustment programs (e.g., CMS, HHS, etc.), and maintain an awareness of audit responses and corrective action plans when necessary.
• Data Analysis and Reporting: Analyze risk-adjusted data, track performance, identify trends, and work closely with data science teams to identify opportunities to improve accurate risk scores. Report findings and recommendations to Risk Adjustment, PPL and Medical Director teams to focus resources.
• Program Optimization: Understand current risk adjustment processes and workflows, and recommend improvements for greater efficiency, accuracy, and effectiveness in capturing risk.
• Coding Accuracy and Education: Provide and support ongoing training for the matrixed teams to stay current with coding standards and risk adjustment methodologies.
• Vendors: Understand relationships with third-party vendors involved in risk adjustment activities, ensuring alignment with provider partnership strategies in support of accurate risk coding.
• Cross-functional Collaboration: Collaborate with other departments such as Risk, Actuarial, Finance, Digital and Compliance to ensure alignment in meeting risk adjustment goals.
• Stakeholder Communication: Provide regular updates on provider-centric risk adjustment program performance, challenges, and strategic initiatives.
• Issue Escalation: Monitor provider risk adjustment issues escalated by PPL Professionals and Medical Directors, provide guidance related to execution of any action plans.
• Provide regular reports and insights on provider performance to Senior Leadership.
• Support contracting and negotiations as needed by the Network Management Team.
• Operational Efficiency: collaborate with other departments to streamline processes, reduce administrative burden, and enhance the provider experience.
• Implement technology solutions (like provider portals) to make interactions more efficient and transparent.
• Strategy & Growth: support Sales and Field Marketing by co-creating and implementing strategies through the PPL markets for expanding and optimizing membership in service of the organization's growth objectives.
• Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where you'll be:

Virtual

Pay Transparency
MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.

We do not request current or historical salary information from candidates.
MVP's Inclusion Statement
At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.

MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.

To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at hr@mvphealthcare.com.

• Tarrytown, NY, USA