Director, Risk Adjustment Prospective Programs

Overview

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an
authentic experience!

Reporting to the Vice President, Risk Adjustment, the Director of Risk Adjustment Prospective Programs is a strategic leader responsible for implementing, operationalizing, and optimizing the health plan's point-of-care, concurrent, and forward-looking risk adjustment initiatives. Unlike traditional retrospective "chart chasing," this role focuses entirely on prospective interventions, capturing accurate member health acuity before or during a provider encounter. This position executes the enterprise strategy and converts it into scalable workflows, controls, KPIs, EHR integrations, and provider-facing tools that reduce friction for independent clinicians and delegated IPAs.

The primary mandate of this position is to ensure the plan's risk adjustment program is a proactive, clinically driven model. Operating within a network structure comprised of independent, Fee-for-Service (FFS) practices and delegated Independent Physician Associations (IPAs), this Director leads programs such as in-home and virtual assessments, pre-visit suspecting, point-of-care documentation supports, and concurrent validation. This leader ensures chronic conditions are documented accurately to CMS compliance standards in real time, driving revenue accuracy and improving proactive clinical care management.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary

State of the art fitness center on-site

Medical Insurance with Dental and Vision

• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance

Flexible Spending Account – Health Care/Childcare

CalPERS retirement

457(b) option with a contribution match

Paid life insurance for employees

Pet care insurance

Key Responsibilities

Prospective Program Design & Execution: Point-of-Care Interventions:
Lead the implementation, optimization, and scalability of the health plan's prospective assessment programs, ensuring that historical chronic conditions and suspected HCC gaps are delivered cleanly to providers at the time of a member's visit
In-Home Assessment Management:
Oversee the strategy, vendor selection, and performance metrics for the plan’s in-home health assessment (IHA) and virtual assessment campaigns for hard-to-reach or disengaged members. Ensure documentation meets compliance standards and integrated with care management
Workflow Burden Reduction: Minimize administrative friction for independent clinicians by building EHR smart-phrases, discrete macros, and pre-visit planning summaries that easily integrate into standard primary care workflows

Provider Engagement & Clinical Advocacy: Value-Based FFS Incentives:
Partner with Contracting and Provider Relations to design and manage prospective "Per-Assessment" incentive programs or quality bonus structures that compensate independent FFS doctors for taking the extra time to complete rigorous documentation
Peer-to-Peer Training:
Oversee the development of tailored prospective education modules for independent clinics on compliance documentation standards (e.g., CMS M.E.A.T (Monitor, Evaluate, Assess, Treat) criteria) at the point of patient encounter
IPA Coordination: Collaborate with delegated IPA Medical Directors to integrate the plan's prospective suspecting data directly into the IPA’s internal care gap and scheduling registries

Advanced Analytics & Suspecting Engine Governance:
Suspecting Models:
Partner with Healthcare Data Analytics teams to optimize "suspecting engines" that evaluate historic claims, prescription data, lab results, and social determinants of health (SDOH) to predict undocumented or under-documented chronic illnesses. Set operational acceptance criteria and feedback loops
Network Tiering:
Segment the FFS provider network based on prospective actionability, focusing high-touch point-of-care tools on clinics with high volumes of "suspected but uncaptured" member HCCs

Cross-Functional Quality & Compliance Synergy:
The "Single Touch" Strategy:
Closely align prospective risk adjustment worksheets and alerts with the Quality/HEDIS team's care gap alerts. Ensure providers receive a unified, comprehensive list of both quality and coding gaps during a patient encounter to eliminate provider abrasion
Clinical Handoffs:
Establish data loops that automatically route newly captured or confirmed complex diagnoses from prospective programs directly into the plan's Case Management and Disease Management pipelines
Prospective Compliance:
Oversee internal validation audits of prospective assessments to guarantee that all codes submitted via these programs are backed by rigorous, compliant clinical documentation, mitigating RADV audit exposure

Submission Pipeline Integrity & Data Integration:
Submission Pipeline Integrity:
Coordinate with Claims/IT/Data Analytics teams on end-to-end submission integrity (encounter/EDPS) to prevent code drop-outs; monitor transaction errors and systemic issues
Data integration:
Maintain operational dashboards for throughput, accuracy, timelines, and ROI of prospective programs; drive root-cause analysis and remediation

Vendor & Budget Oversight: Vendor Oversight:
Support selection, contracting, and ongoing performance management of vendors (in home assessments, point of care tools, NLP/AI aids); track SLAs, data security obligations, and ROI.
Budget Oversight:
Manage budgets and resource allocations

Team Leadership

Lead and develop a high-performance, engaged, and accountable team culture. Provide strategic talent guidance, oversee performance and workforce planning, and ensure clear communication and effective change leadership across the business unit. Hire, train, and manage staff, while monitoring and evaluating outcomes. Conduct performance reviews of each Team Member within IEHP guidelines

Governance, Reporting & Continuous Improvement:
Governance & Reporting:
Maintain governance items (SOPs, controls, audit trails). Produce routine results reporting to senior leadership and committees
Continuous Improvement:
Identify process improvements and technology enhancements to increase provider adoption and documentation accuracy

Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Requirement

• A minimum of eight (8) years of progressive experience in healthcare managed care or risk adjustment operations, with a distinct, heavy emphasis on executing prospective (point-of-care, in-home, or concurrent) programs. At least five (5) years of leadership and management experience leading teams, projects, initiatives, and/or cross-functional groups. Demonstrated success improving compliant documentation capture, provider adoption, and submission integrity through EHR integrations and analytics driven suspecting
• Bachelor’s degree in nursing, public health, healthcare administration or a related field from an accredited institution required
• Master’s degree in nursing, public health, healthcare administration or a related field from an accredited institution preferred
• Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC) from AAPC or AHIMA required
• CDI certification (e.g., ACDIS CCDS) or comparable documentation improvement credential preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) or Nurse Practition