AVP, Medicare Risk Adjustment Performance

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Assistant Vice President, Medicare Risk Adjustment Performance provides executive leadership for Alignment's enterprise Risk Adjustment performance strategy and operations. The role is accountable for achieving annual RAF performance objectives, driving provider and market execution, and ensuring Risk Adjustment activities support the organization's financial, operational, and strategic objectives.

The AVP leads the development and execution of enterprise prospective, concurrent, and retrospective Risk Adjustment strategies and serves as the executive responsible for operational performance across provider engagement, coding operations, chart retrieval, submission, analytics, vendor management, and revenue realization.

The role partners closely with Market Operations, Network Management, Clinical Operations, Finance, Compliance, and Data & Technology teams to ensure enterprise Risk Adjustment goals are achieved while supporting audit readiness, provider performance improvement, and long-term organizational growth.

Enterprise Accountability

• Accountable for enterprise RAF performance outcomes and annual Risk Adjustment targets.
• Responsible for prospective, concurrent, and retrospective Risk Adjustment execution strategies.
• Provides executive oversight for chart retrieval, coding production, provider engagement, and coding submission performance.
• Establishes market and provider performance objectives and monitors achievement of operational results.
• Provides executive reporting and recommendations to senior leadership regarding Risk Adjustment performance, opportunities, risks, and resource needs.
• Oversees strategic vendor partnerships supporting enterprise Risk Adjustment capabilities.

General Duties/Responsibilities (May include but are not limited to):

• Lead the annual operating plan for Medicare risk adjustment performance, including goals, measures, milestones, resources and market-level execution plans.
• Provide leadership across prospective, concurrent and retrospective programs, including annual wellness visit support, suspecting and recapture initiatives, chart retrieval, coding production and submission readiness.
• Establish and monitor performance guidelines for quality, productivity, service levels and financial outcomes; ensure timely executive reporting and action-oriented performance reviews.
• Use risk adjustment analytics, reporting and strategic business analysis to identify opportunities, risks, root causes and interventions across markets, provider groups and programs.

Finance

• Accountable for partnership with Finance and Actuarial teams to forecast RAF performance, evaluate revenue implications, monitor financial outcomes, and improve forecast accuracy across markets and programs.
• Support bid development, revenue forecasting, and long-range planning activities.
• Evaluate financial impact of provider performance, coding initiatives, and operational investments.
• Provide executive visibility into Risk Adjustment financial performance and variances.

Vendor Ownership

• Establish strategic direction and performance expectations for Risk Adjustment vendors and external partners.
• Oversee vendor contracts, service delivery, productivity, quality, compliance, and business outcomes.
• Ensure vendor capabilities align with enterprise Risk Adjustment strategy and future-state operating models.

Provider Relationships

• Serve as executive sponsor for provider coding performance and documentation improvement initiatives.
• Partner with Network Management, Market Operations and provider leadership to improve enterprise Risk Adjustment outcomes.
• Lead provider performance reviews, corrective action planning, and performance improvement initiatives across delegated and non-delegated arrangements.
• Establish accountability frameworks for IPA, provider and vendor performance.

• Develop scalable reporting, analytical and operational capabilities that improve organizational visibility, support audit readiness and reduce reliance on manual controls.

Data & Technology Strategy

• Partner with DTS and enterprise analytics teams on Risk Adjustment data strategy and reporting capabilities.
• Define business requirements supporting workflow modernization, automation, provider enablement, and enterprise reporting.
• Sponsor technology initiatives that improve scalability, productivity, transparency, and audit readiness.
• Drive adoption of modern analytics capabilities supporting provider and market performance management.

Revenue Integrity & RADV Readiness Support

• Ensure chart retrieval, coding production, provider engagement, and submission activities support enterprise RADV readiness objectives.
• Partner with the AVP, Risk Adjustment Integrity & Transformation on validation findings, reconciliation activities, diagnosis corrections, and audit remediation initiatives.
• Establish operational accountability for issues impacting diagnosis accuracy, documentation support, evidence availability, and revenue sustainability.
• Support development of the enterprise MRA business case and modernization initiatives supporting long-term Risk Adjustment performance and audit readiness.
• Establish policies, procedures, standard work and governance routines that support accurate and compliant execution across products and markets.
• Maintain knowledge of CMS risk adjustment requirements, model changes and regulatory guidance, and translate changes into operational plans, training and performance expectations.
• Communicate complex operational, technical and financial information as clear executive insights, decisions and business narratives.
• Build, mentor and retain a high-performing multidisciplinary team and foster cross-functional accountability and continuous improvement.
• Perform other duties as assigned.

Strategy & Business Planning

• Develop multi-year Risk Adjustment performance strategies aligned with enterprise growth objectives.
• Establish annual goals, objectives, key performance indicators, and resource requirements.
• Lead business case development for Risk Adjustment investments, operational initiatives, and technology capabilities.
• Partner with executive leadership on future-state operating model decisions.
• Support enterprise budgeting, forecasting, and strategic planning processes.

Primary Control Points and Outcomes

• Provider workflow enablement: actionable information reaches providers and market teams in time to support appropriate documentation and intervention.
• Diagnosis capture: eligible opportunities are addressed through compliant prospective, concurrent and retrospective programs.
• Coding and submission: diagnoses are coded accurately, processed efficiently and submitted through controlled workflows.
• Performance intelligence: leaders have timely, consistent and decision-ready views of RAF, coding, provider, vendor and market performance.

Supervisory Responsibilities:

Oversees assigned leaders and staff. Responsibilities include workforce planning, recruiting, selecting, orienting and training employees; assigning work; setting goals; monitoring and appraising results; coaching and developing talent; and addressing performance in accordance with company policy.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.The requirements listed below are representative of the knowledge, skill, and/or ability required.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Experience:

Ten or more years of progressive experience in managed care, Medicare Advantage, healthcare analytics, healthcare finance, risk adjustment, population health or related operations.

Experience leading enterprise Risk Adjustment programs across multiple markets and provider arrangements.

Demonstrated responsibility for financial performance, forecasting, strategic planning, or major business initiatives.

Proven track record managing executive stakeholders and enterprise-wide programs.

Seven or more years of people leadership, including development of high-performing analytical or operational teams.

Education/Licensure:

Bachelor’s degree in healthcare, business, finance, analytics, information systems or a related field, or equivalent relevant experience.

Advanced degree preferred.

Other:

Demonstrated knowledge of CMS-HCC risk adjustment methodology, Medicare Advantage reimbursement, coding and documentation programs, encounter data, and performance measurement.

Demonstrated experience designing or leading analytics, reporting, data governance or scalable data infrastructure that supports reporting accuracy, regulatory compliance and audit readiness.

Experience leading complex cross-functional initiatives and working with executives, providers, vendors, compliance partners and technical teams.

Experience with risk adjustment forecasting, provider performance analytics, data warehousing, SQL-based analytics or business intelligence platforms.

Experience supporting multiple government-program lines of business or large, multi-market Medicare Advantage operations.

Advanced ability to translate complex data into executive-level insights, recommendations and action plans.

Strong verbal, written, presentation, organization and relationship-management skills.

Computer Skills:

Must be efficient in Excel and preferred with SQL knowledge.

Other Skills and Abilities:

Good organization skills

Good analytical skills

Good interpersonal skills

Strong communication skills

Success Measures

Achievement of annual RAF and Risk Adjustment performance goals.

Provider performance improvement across targeted markets and organizations.

Improvement in coding productivity, chart retrieval effectiveness, and submission performance.

Reduction in operational barriers impacting Risk Adjustment outcomes.

Support of enterprise RADV readiness and revenue integrity objectives.

Delivery of strategic business initiatives supporting future-state Risk Adjustment transformation.

Work Environment:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $198,219.00 - $297,329.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

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