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Director Medicare Risk Adjustment Jobs (NOW HIRING)

Mass Advantage

Manager, Risk Adjustment

Worcester, MA · On-site

... Medicare Advantage risk adjustment, with at least 3 years in a plan-side role (not solely provider-side or vendor-side). * Direct, hands-on RADV experience - working fluency with the CMS-HCC model ...

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Director Medicare Risk Adjustment information

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$102K

$135.9K

$143.5K

How much do director medicare risk adjustment jobs pay per year?

As of Jun 12, 2026, the average yearly pay for director medicare risk adjustment in the United States is $135,863.00, according to ZipRecruiter salary data. Most workers in this role earn between $137,500.00 and $141,000.00 per year, depending on experience, location, and employer.

What does a Director of Medicare Risk Adjustment do?

A Director of Medicare Risk Adjustment oversees the strategy, operations, and compliance of risk adjustment programs for Medicare Advantage plans. They ensure accurate data collection, coding, and submissions to optimize reimbursement while maintaining regulatory compliance. This role involves collaborating with cross-functional teams, managing analytics, and implementing initiatives to improve documentation and risk score accuracy. Additionally, they monitor policy changes and adjust processes to align with evolving CMS regulations.

What are some common challenges faced by Directors of Medicare Risk Adjustment, and how do they impact daily work?

Directors of Medicare Risk Adjustment frequently tackle challenges such as interpreting evolving CMS guidelines, ensuring complete and accurate documentation, and aligning interdepartmental teams around risk adjustment best practices. Keeping up with regulatory changes, managing large data sets, and training staff on coding compliance are all critical aspects of the job. These challenges require strong analytical skills, attention to detail, and the ability to communicate complex information to various stakeholders. Addressing these issues effectively is key to maintaining compliance, optimizing revenue accuracy, and helping your organization deliver quality care to Medicare populations.

What are the key skills and qualifications needed to thrive in the Director Medicare Risk Adjustment position, and why are they important?

To thrive as a Director Medicare Risk Adjustment, you need a strong background in healthcare administration, Medicare regulations, data analytics, and risk adjustment methodologies, often supported by a bachelor's or master's degree in a related field. Familiarity with risk adjustment software, claims processing systems, and proficiency in data analysis tools like SQL or SAS is essential, and certifications such as CRC (Certified Risk Adjustment Coder) can be advantageous. Outstanding leadership, cross-functional collaboration, and strong communication skills help drive teams toward accurate documentation and coding compliance. These competencies are crucial for optimizing revenue, ensuring regulatory adherence, and guiding strategic organizational initiatives in a complex healthcare environment.

More about Director Medicare Risk Adjustment jobs
What cities are hiring for Director Medicare Risk Adjustment jobs? Cities with the most Director Medicare Risk Adjustment job openings:
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Director Medicare Risk Adjustment jobs near you
Infographic showing various Director Medicare Risk Adjustment job openings in the United States as of June 2026, with employment types broken down into 7% As Needed, 46% Full Time, 43% Part Time, and 4% Contract. Highlights an 93% Physical, 1% Hybrid, and 6% Remote job distribution, with an average salary of $135,863 per year, or $65.3 per hour.
Director, Risk Adjustment - Hybrid

Director, Risk Adjustment - Hybrid

EmblemHealth

New York, NY • Hybrid

Other

Posted 24 days ago

Job description

Summary of Job

Develop and execute a comprehensive annual Risk Adjustment strategy that supports the Company strategies and improves the quality of care delivered to Emblem members, and to ensure the plan reimbursement accurately reflects the clinical diagnosis of our Medicare, Medicaid, and Affordable Care Act (ACA) members.  Develop and execute an annual Provider Risk Adjustment strategy to improve the accuracy of their diagnosis coding through education and engagement of our risk adjustment programs, reimbursement models and the ongoing development/ enhancement of support capabilities that complement their clinical practice model.  Prepare and present provider risk adjustment results at all Emblem joint operating committee meetings and monthly risk adjustment operational meetings.  Select and manage best-in-class risk adjustment vendors to drive continual improvement in the accuracy of diagnosis coding for Medicare, Medicaid, and ACA members.  Manage the ongoing performance, compliance and return on investment for each risk adjustment vendor.  Create and maintain a capabilities framework that is member and provider centric and is appropriate given for the clinical and demographic dynamics of members in risk adjusted products.  Manage the creation and timely production of risk adjustment operation and financial performance reports for all risk adjustment programs, and lead monthly risk adjustment operation meetings with Emblem leaders for VP, Risk Adjustment.  Be a strategic partner with the Actuarial, Quality and Product teams to enhance risk adjustment interventions and results.  Establish enterprise-wide monitoring and reconciliation reports to ensure that risk adjustment vendor results are accurately, timely and completely submitted to government entities.

Responsibilities

  • Develop, manage, and improve all retrospective risk adjustment programs to retrospectively identify, retrieve, code and submit diagnostic information from providers on EmblemHealth members enrolled in Medicare, Medicaid, and ACA products; manage all vendor relationships that support these retrospective activities.
     
  • Develop, manage, and improve prospective and concurrent risk adjustment programs to ensure accurate capture and reporting of diagnostic information for EmblemHealth members enrolled in Medicare, Medicaid and ACA products. 
     
  • Work with risk adjustment vendors and providers to execute in office assessment programs through which they 1) identify members based on clinical needs and quality gaps, 2) outreach to patients to encourage them to make office visits to receive services and 3) completely and accurately document all diagnostic conditions. 
     
  • Manage the In-Home Assessment risk adjustment vendor program.
     
  • Manage team completing revenue management opportunities for Medicaid, Medicare and Health Exchange products which includes identification of risk score opportunities, suspects, analysis and tracking of performance and attribution of interventions.
     
  • Direct EmblemHealth provider relationship and engagement risk adjustment activities.
     
  • Direct interaction with the CFO, CEO and other physician leaders of ACPNY groups and other large, sophisticated medical groups to integrate our programs into the provider's operations.
     
  • Analyze data to identify submission trends against historic data and membership changes and recommend opportunities to improve accuracy and completeness of all government submissions.
     
  • Collaborate with EmblemHealth medical management, quality, marketing & sales and network departments to identify opportunities to achieve efficiencies and improve effectiveness of risk adjustment activities by integrating both prospective and retrospective programs with care management, CMS Stars, Medicaid and Health Exchange quality programs, sales outreach and provider contracting. 

Qualifications

  • Bachelor's Degree in Healthcare, Finance, Business, or related field  (Required); Master's degree  (Preferred)
     
  • 10 - 12+ years of relevant, professional work experience  (Required)
     
  • Experience in healthcare, plan or provider operations and relations or related experience  (Required)
     
  • Leadership experience - including staff and process management experience  (Required)
     
  • Risk adjustment knowledge and expertise across Medicare, Medicaid, and Commercial exchange  (Required)
     
  • Capacity to multi-task at high detail-oriented level  (Required)
     
  • Strong communication skills (verbal, written, presentation, interpersonal) including executive leaders meeting experience  (Required)
     
  • Strong working knowledge of MS Office - Word, Excel, PowerPoint, Access, Outlook  (Required)
     
  • Strong analytical and logical skills paired with strong attention to detail  (Required)
Additional Information
  • Requisition ID: 1000003033
  • Hiring Range: $135,000-$253,800

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