Loss Control Report Reviewer Jobs in Remote, OR (NOW HIRING)

Position: Director of Quality and Risk Adjustment

Location: Coos Bay, OR • Hybrid (onsite/remote)

Job Id: 309 • # of Openings: 1

The Director of Quality and Risk Adjustment provides strategic leadership for the development, implementation, oversight, and continuous improvement of organizational quality, risk adjustment, population health, and performance improvement programs. This role collaborates with leadership, providers, and cross-functional teams to improve member outcomes, support value-based care initiatives, enhance revenue integrity, and drive organizational performance through data-informed decision making.

• Bachelor’s degree in Healthcare Administration, Public Health, Nursing, Business Administration, Health Information Management, or a related field required
• Master’s degree in a related field strongly preferred
• Minimum of five years of progressively responsible leadership experience in healthcare quality improvement, performance improvement, risk adjustment, managed care, value-based payment models, or related healthcare operations
• Three to five years’ experience in Medicaid risk adjustment and coding
• Minimum three years’ experience in a medical office, clinic, or healthcare administration setting
• Experience training, educating, and guiding providers and clinical staff; experience leading and managing a team
• Certified Professional Coder or Certified Risk Adjustment Coder, willing to obtain within the first year of hire

• Develop and execute the organization’s strategic vision for quality improvement, risk adjustment optimization, and performance improvement initiatives
• Lead design, implementation, evaluation, and continuous improvement of quality and risk adjustment programs
• Establish departmental goals, KPIs, and performance improvement strategies aligned with organizational priorities
• Advise executive leadership on quality outcomes, risk adjustment performance, population health, value-based reimbursement, and regulatory requirements
• Identify trends, risks, opportunities, and best practices; develop proactive strategies to support organizational success
• Foster a culture of continuous quality improvement, accountability, and data-driven decision-making
• Collaborate with leaders, providers, vendors, and stakeholders to advance quality and risk adjustment initiatives

• Oversee the Quality Management Improvement (QMI) Program, Transformation and Quality Strategy (TQS), and related quality initiatives
• Develop and monitor quality improvement strategies that support contractual obligations, regulatory requirements, and population health
• Direct the development of evaluation tools, performance metrics, dashboards, and reporting systems
• Lead efforts to improve quality performance measures, incentive metrics, outcomes, member experience, and provider performance
• Monitor performance and implement corrective action plans as needed
• Oversee data validation, analysis, interpretation, and reporting of quality and performance data
• Ensure compliance with applicable federal, state, accreditation, contractual, and regulatory quality requirements
• Prepare and submit quality reports, performance improvement reports, and contractual deliverables
• Provide leadership to quality-related committees, workgroups, and partnerships
• Collaborate to identify opportunities for systems transformation and process improvement
• Monitor delegated vendor performance and implement corrective actions when necessary
• Oversee readiness activities for audits, regulatory reviews, accreditation, and external quality reviews
• Provide strategic direction for all organizational risk adjustment activities and related strategies
• Monitor risk adjustment performance metrics, coding accuracy, and documentation integrity
• Direct provider education, engagement, and incentive strategies to support accurate documentation and coding
• Utilize analytics to identify trends and opportunities for risk adjustment improvement
• Oversee relationships with risk adjustment vendors and external partners
• Implement auditing and monitoring activities to evaluate documentation quality and program compliance
• Collaborate with internal and external stakeholders to resolve risk adjustment issues
• Develop and maintain policies, procedures, and workflows for risk adjustment activities
• Monitor changes in risk adjustment methodologies and regulatory requirements

• Provide strategic oversight of quality performance, risk adjustment analytics, and population health metrics
• Develop and report KPIs, dashboards, and scorecards to support data-driven decisions
• Analyze data to identify trends, care gaps, and opportunities for improvement in quality and risk adjustment
• Communicate performance data to executives, providers, and stakeholders
• Collaborate to implement performance improvement strategies that enhance member outcomes and operational effectiveness
• Monitor performance against contractual, regulatory, payer, and organizational benchmarks and develop corrective actions as needed
• Ensure data integrity and effective use of data to support improvement initiatives
• Participate in process improvement activities and promote a culture of risk management and quality
• Foster ethics, integrity, and professional conduct; represent the organization at meetings and conferences as applicable

• Comprehensive knowledge of healthcare quality improvement, population health, risk adjustment, value-based care, Medicaid managed care, and regulatory requirements
• Ability to lead programs, analyze data, implement improvements, engage providers, and drive performance through evidence-based decisions
• Ability to translate complex data into actionable recommendations and communicate results to leadership and stakeholders
• Strong leadership, relationship management, and cross-functional collaboration skills
• Knowledge of clinical documentation improvement, medical coding (ICD-10, CPT, HCPCS), HEDIS, and quality measurement frameworks
• Understanding of managed care concepts and basic health equity considerations
• Attention to detail, initiative, judgment, and decision-making
• Proficiency in Microsoft Office and Windows OS
• Ability to work with diverse populations and handle sensitive situations professionally
• Knowledge of federal and state laws including OSHA, HIPAA, and other relevant regulations

This position may be primarily remote with occasional onsite work. Travel locally may be required; own transportation may be necessary. Hours may vary based on operational needs.

This job description is intended to provide basic guidelines for meeting job requirements. It is not a comprehensive listing of activities, duties, or responsibilities and may change at any time with or without notice.