Director, Risk Adjustment Operations

Role Overview

• This role owns the end-to-end operational success of two core pillars within Devoted’s Risk Adjustment Department: Data Submissions and the Retrospective Chart Review Program.
• Lead the teams responsible for the successful submission of Devoted’s disease burden reporting by optimizing our internally developed Centers for Medicare & Medicaid Services (CMS) data submission engine.
• Manage a high volume, multi-vendor retrospective medical document review operation.
• Develop, implement, and achieve KPIs that measure and monitor the successful submission of our risk adjustment data.
• Manage relationship with Devoted’s data submission pass-through vendor, and CSCC Operations, CMS’ data submission team.
• Read and make determinations on how new and emerging CMS technical guidance impacts our data submission operations.
• Maintain our data submission policies, including our policy on how we internally validate, clean, and apply inclusion and exclusion criteria to the data we submit to CMS.
• Support other areas of the Risk Adjustment department to ensure end-to-end perspectives are considered for all policy and procedure decisions.
• Lead the strategic execution of the multi-channel Retrospective Chart Review Program, including defining, monitoring, and enforcing rigorous Service Level Agreements (SLAs) and Key Performance Indicators (KPIs) for internal teams, offshore partners, and external vendors.
• Oversee medical record retrieval in partnership with the Clinical Data Acquisition team.
• Own and improve program forecasts and capacity modeling.
• Evaluate and integrate AI technologies to optimize the end-to-end chart review workflow, from medical record retrieval through evaluation.
• Support QA and audit processes to achieve or exceed 95% coding accuracy.
• Support other areas of the Risk Adjustment department to ensure end-to-end perspectives are considered for all policy and procedure decisions.

Requirements

• Proven operator with a track record of transforming complex operational challenges into scalable, practical, and elegant business processes
• Systematic and detail-oriented approach to leadership, with a fierce commitment to quality, accuracy, and operational excellence
• Deeply analytical and research-oriented, with the ability to digest intricate regulatory or technical guidance and seamlessly incorporate it into daily operations
• Ability to manage and lead through ambiguity
• Can-do attitude and stamina for tackling hard problems
• High level of self-motivation and an ability to balance multiple priorities across initiatives
• Results-oriented: you are energized by having an ambitious goal and the latitude to execute against it
• Natural relationship builder and able to work well in a cross functional team environment
• Experience managing multiple teams and vendors
• Fast learner, can pick up new content/industries quickly in an extremely fast-paced tech environment
• Proven organizational, communication, and leadership skills
• Prior experience in Medicare Advantage risk adjustment, in particular RAPS and EDPS data submission and retrospective chart reviews preferred but not required.

Benefits

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....