Director, Risk Adjustment Prospective Programs

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.

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

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 Practitioner (NP) license issued by the California BRN preferred

Key Qualifications

Must have a valid California Driver’s license

Comprehensive knowledge and in-depth understanding of: Launching healthcare operations or behavioral change campaigns within a non-employed, independent FFS provider network

Prospective risk adjustment platforms, EHR alert integrations (Epic, Athena, eClinicalWorks, etc.)

Managing large-scale national prospective/IHA vendors (e.g., Signify, Matrix, Optum)

Program management, change management, and stakeholder facilitation for provider audiences. Vendor management (SLAs, ROI, data security) and budget stewardship

Prospective risk adjustment concepts and operations; documentation standards (ICD 10 CM/HCC, MEAT), HIPAA/privacy; RADV readiness principles

Encounter/EDPS submission mechanics and downstream data quality controls

Exceptional communicator capable of convincing fiercely independent, time crunched FFS providers to adopt prospective tools into their daily workflows

Data literacy (Excel/BI tools) to monitor KPIs and communicate insights clearly

Ability to balance prospective/concurrent capture with compliance and audit readiness

Intermediate–advanced skills in using analytics tools (e.g., Excel, BI tools)

Strong presentation and facilitation skills for varied clinical audiences

Advanced ability to: Build immediate peer-to-peer credibility with network physicians

Model change leadership, clear communication, and cross‑functional collaboration

Maintain strong professional relationships with providers, internal stakeholders, and external partners

Act as a credible advocate for prospective documentation excellence, while ensuring alignment with company policies and strategies

Prioritize resources using network tiering

Drive measurable outcomes while maintaining strong provider relationships

Start your journey towards a thriving future with IEHP and apply TODAY !