Hcc Risk Adjustment Jobs in Houston, TX (NOW HIRING)

Job Title:  Senior Director, Network Management

Supervisor: SVP, Market Operations and Growth

Required License(s)/ Certification(s): None Required

FLSA Status: Exempt

Travel: 30-50&

Summary: 

The Senior Director, Network Management is a market-facing executive who architects, builds, and optimizes high-performing provider networks that power value-based and risk-bearing arrangements for Apex Health Solutions and its client partners. Reporting to the SVP, Network Management, this leader owns provider network development across every Apex client market — with immediate accountability to build the Houston market network from the ground up (primary care, specialists, hospitals, ancillary, and post-acute). The role sits at the intersection of payer strategy, provider partnership, and clinical-financial performance: leading MA full- and partial-risk contracting, translating actuarial and MLR economics into contract structures, and standing up the people, process, and analytics to sustain network performance at scale. The ideal candidate has built or materially expanded a provider network for an IPA, CIN, MSO, or risk-bearing entity, and brings Houston-market relationships that can be activated on day one.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

•   Own the multi-year network strategy across all Apex client markets — aligning network design with membership growth, product mix (MA HMO/PPO/DSNP, MSSP, ACO REACH, commercial VBC), and risk posture.

•   Design and execute the Houston and other market builds: PCP anchor recruitment, specialist tiering, hospital and health-system participation, and ancillary contracting (SNF, HH, DME, imaging, lab, dialysis, infusion).

•   Understand client network against CMS, TDI, and NCQA standards, STAR ratings, or member experience.

•   Serve as the face of Apex to, medical group presidents, and physician owners; personally lead complex negotiations and cultivate a proprietary bench of provider relationships across multiple markets.

•   Lead negotiation of provider contracts across the full risk continuum — FFS, upside-only shared savings, two-sided risk, sub-cap, global capitation, percent-of-premium, and full-risk delegated arrangements.

•   Ability to structure Medicare Advantage risk deals that align PMPM economics, benchmark methodology, quality gates (HEDIS/STARS), risk adjustment accuracy, and TCoC accountability — with clear stop-loss, reconciliation, and dispute mechanics.

•   Assist market operations practice performance representatives with risk-bearing entity operations — IPA, CIN, MSO, ACO, and delegated risk structures — including CMS delegation, DOI solvency, and downstream risk-sharing.

•   Build and stand up IPA and CIN structures where required: governance, Stark/AKS-compliant clinical integration, physician alignment economics, quality withholds, and shared-savings waterfalls that recruit and retain high performers.

•   Partner with Actuarial and Finance to translate MLR targets and medical-expense assumptions into contract terms; pressure-test every deal before signature.

•   Own network cost of care, unit-cost trend, utilization mix, and leakage across contracted providers; partner with Analytics and Market Operations on dashboards, monthly operating reviews, JOCs, and QBRs.

•   Build the network operations infrastructure: contract lifecycle management, delegated credentialing oversight, provider data integrity, fee-schedule loading, and regulatory reporting (CMS, TDI, other state DOIs, NCQA, No Surprises Act).

•   Drive provider engagement and education on VBC economics, coding accuracy, HCC recapture, HEDIS/STARS closure, and utilization management.

•   Represent Apex in client audits and regulatory examinations; maintain audit-ready policies and procedures that are repeatable across markets.

•   Build, coach, and retain a high-performing network team across contracting, provider relations, and analytics; grow leaders capable of standing up future markets.

Candidate Qualifications

Education

•   Required: Bachelor’s in Healthcare Administration, Business, Finance, Public Health, or related field.

•   Preferred: Master’s (MHA, MBA, MPH, JD) or equivalent experience in managed care, actuarial, or provider economics.

Skills

•   Advanced: value-based contract design; executive-level negotiation; MA economics and Star/RAF fluency; financial acumen against PMPM/TCoC; leadership in matrixed environments; executive communication and influence.

•   Intermediate: regulatory command of CMS MA, MSSP, ACO REACH, TDI, NCQA, HIPAA, Stark/AKS; familiarity with contract lifecycle, credentialing, and provider data systems (Facets, HealthEdge, NetworX, Availity, symplr); Microsoft Excel modeling, PowerPoint, Word.

Experience

•   7+ years of progressive provider network development, contracting, and management within a health plan, IPA, CIN, MSO, ACO, or other risk-bearing entity; 7+ years leading contracting and/or provider relations teams.

•   Demonstrated track record standing up or materially expanding a provider network in a new geography — Houston or comparable metro; existing Houston relationships strongly preferred.

•   Deep experience negotiating and operationalizing Medicare Advantage risk contracts (full/partial cap, global cap, percent-of-premium, delegated).

•   Current, working knowledge of MA economics — bid mechanics, benchmark and rebate flow, Star Ratings, HCC/RAF risk adjustment, MLR — and of what constitutes a risk-bearing entity (CMS delegation, DOI solvency/reserves, stop-loss, downstream risk).

•   Hands-on experience developing IPA and/or CIN networks: governance, physician alignment economics, and clinical integration.

•   Preferred: prior role at a top-decile MA health plan, risk-bearing physician platform, or MSSP/ACO REACH participant; experience translating actuarial models into contract structure.

About Apex Health Solutions

Apex Health is a tech-enabled management services organization that enhances the enterprise value of health systems by transforming physician networks into strategic assets. More than a consultant, Apex embeds as a long-term partner to drive sustainable performance across provider enablement, quality, network growth, and value-based care. With proven success at leading health systems, Apex helps clients preserve local control over care delivery and financing, rather than outsourcing it to national insurers.