Work From Home Risk Adjustment Auditor Jobs in Washington

Why Join CINQCARE?

CINQCARE is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Position Overview

The Sr. Director of Risk Adjustment is a senior leader responsible for designing, executing, and continuously improving CINQCARE's enterprise-wide risk adjustment strategy. This data science-forward role leverages advanced analytics, machine learning, and predictive modeling to maximize risk score accuracy, optimize reimbursement, and drive population health outcomes across Medicare Advantage, Medicaid Managed Care, and ACO REACH programs. The Sr. Director will lead a multidisciplinary team of analysts, data scientists, and program specialists while partnering closely with clinical, finance, and technology leadership.

Key Responsibilities

• Develop and own the enterprise risk adjustment analytics strategy, roadmap, and governance framework across all lines of business including Medicare Advantage, Medicaid Managed Care, and ACO REACH.

• Lead a team of data scientists, senior analysts, and program staff; set vision, define priorities, and foster a high-performance analytics culture.

• Build and deploy predictive models (e.g., HCC suspecting, gap closure prioritization, RAF trajectory forecasting) using Python, R, or equivalent tools.

• Oversee end-to-end data pipeline design including claims data ingestion, encounter data reconciliation, and integration with EMR/EHR platforms.

• Translate complex data science outputs into actionable clinical and operational insights for executive leadership, clinical teams, and provider partners.

• Direct retrospective and prospective chart review programs; manage vendor relationships and performance against contractual KPIs.

• Establish and maintain a comprehensive analytics infrastructure for HCC performance monitoring, coding completeness, and audit-readiness dashboards.

• Partner with Finance to quantify risk adjustment revenue impact and build multi-year financial forecasting models.

• Serve as the subject matter expert on CMS-HCC, HHS-HCC, and CDPS models; monitor regulatory changes and adjust strategy proactively.

• Champion clinical documentation improvement (CDI) initiatives in collaboration with clinical and provider engagement teams.

• Present risk adjustment performance, trends, and strategic recommendations to C-suite and Board-level stakeholders.

• Ensure all programs are compliant with CMS guidelines, ICD-10 coding standards, and organizational policies.

Required Qualifications

Education:

• Master's or doctoral degree in Data Science, Biostatistics, Health Informatics, Mathematics, or a closely related quantitative field.

Experience:

• 10+ years of progressive experience in risk adjustment, with at least 3 years in a senior leadership role.
• Experience in value-based care, ACO, or managed care organizations (preferred).

Certifications:

• Certified Risk Adjustment Coder (CRC) or similar credential is a plus.

Technical Skills:

• Deep expertise in CMS-HCC, HHS-HCC, and CDPS risk adjustment models.
• Advanced proficiency in Python and/or R for statistical modeling, machine learning, and large-scale data analysis.
• Strong command of SQL and experience working with claims, encounter, and clinical datasets in cloud or on-premises data environments (e.g., Snowflake, Databricks, Redshift).
• Familiarity with NLP/text mining techniques applied to clinical documentation (preferred).
• Experience with BI platforms (Power BI, Tableau) and data visualization best practices (preferred).
• Demonstrated experience building and deploying predictive models in a healthcare payer or provider setting.

Soft Skills:

• Proven ability to lead and develop high-performing, cross-functional teams.
• Exceptional executive communication and data storytelling skills.

The working environment and physical requirements of the job include:

In-office work is performed indoors in a traditional office setting with conditioned air, artificial light, and an open workspace.

In this position you will need an to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Equal Opportunity & Reasonable Accommodation Statement

CINQCARE is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require a reasonable accommodation during the application or employment process, please indicate this in your application or speak with your recruiter during the hiring process.

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.

Our Benefits

At CINQCARE, we care for our team like we care for our patients—holistically. We offer flexible, comprehensive benefits so you can thrive while delivering top-notch care.

• Medical Plans: Two comprehensive options offered to Team members.
• 401K: 4% employer match for your future.
• Dental & Vision: Flexible plans with in-network savings.
• Paid Time Off: Generous PTO, holidays, and wellness time.
• Extras: Pet insurance, commuter benefits, mileage reimbursement, CME for providers, and company-provided phones for field staff.