SVP, Quality, Risk Adjustment, & Documentation

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    "title": "SVP, Quality, Risk Adjustment, & Documentation",
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    "datePosted": "2024-06-06T08:37:35.001Z",
    "description": "<h2>Job Summary</h2>\n<p><strong>Job Summary</strong> </p>\n<p>The SVP of Quality, Risk Adjustment & Documentation is a senior enterprise leader accountable for integrating and transforming three deeply interdependent functions: clinical quality performance, risk adjustment (RAF), and clinical documentation integrity. This role is revenue-critical; quality scores and RAF scores are the primary drivers of payer performance and financial sustainability in WellBe’s value-based care model. </p>\n<p> </p>\n<p>This is a fix-and-transform mandate. The SVP will be expected to stabilize underperforming operations, establish clear accountability structures, eliminate fragmentation, and build a unified, high-performing function that drives measurable outcomes. The successful leader will bring both strategic vision and hands-on execution capability, with a demonstrated record of improving payer performance in complex, fast-scaling healthcare environments. </p>\n<h2>Job Description</h2>\n<p><strong>FLSA Status: Exempt</strong></p>\n<p><strong>Compensation: $250k-$330k</strong></p>\n<p><strong>Location: Remote/Hybrid</strong></p>\n<p><strong>Travel: Up to 20% as business needs require </strong></p>\n<p><strong>Supervisor Responsibilities: 4 Direct Reports and multiple indirects </strong></p>\n<p><strong>Essential Duties and Responsibilities</strong> </p>\n<p><strong>Enterprise Quality & Clinical Performance</strong> </p>\n<ul>\n <li>Lead enterprise strategy and execution for clinical quality outcomes, including performance against payer-driven metrics such as STARS and HEDIS. </li>\n</ul>\n<ul>\n <li>Establish governance, reporting, and accountability structures to drive measurable, sustained improvement across all quality programs. </li>\n</ul>\n<ul>\n <li>Partner with medical and clinical leadership to close care gaps, align documentation practices with quality performance goals, and drive outcomes across markets. </li>\n</ul>\n<ul>\n <li>Serve as the enterprise authority on quality program strategy, ensuring alignment between clinical operations and payer performance expectations. </li>\n</ul>\n<p> </p>\n<p><strong>Risk Adjustment (RAF) Strategy & Execution</strong> </p>\n<ul>\n <li>Own end-to-end risk adjustment strategy, execution, and performance, including HCC coding accuracy, RAF score optimization, and revenue integrity. </li>\n</ul>\n<ul>\n <li>Partner with actuarial and finance teams to develop data-driven risk adjustment projections and revenue forecasts aligned to enterprise financial goals. </li>\n</ul>\n<ul>\n <li>Engage Medicare Advantage payers to align on coding strategies, compliance requirements, and contract performance. </li>\n</ul>\n<ul>\n <li>Identify and remediate gaps in RAF score captures, coding accuracy, and workflow execution; implement controls to reduce compliance risk and financial exposure. </li>\n</ul>\n<ul>\n <li>Lead and manage all risk adjustment-related audits, including CMS RADV, OIG reviews, and payer audits, ensuring robust risk mitigation and audit readiness. </li>\n</ul>\n<ul>\n <li>Oversee third-party risk adjustment vendors, ensuring compliance, contract optimization, and performance alignment. </li>\n</ul>\n<ul>\n <li>Lead onboarding and integration of new health plan partners, supporting market expansion with scalable risk adjustment infrastructure. </li>\n</ul>\n<p> </p>\n<p><strong>Clinical Documentation Integrity</strong> </p>\n<ul>\n <li>Oversee the clinical documentation improvement (CDI) program, ensuring documentation accuracy, completeness, and alignment with regulatory and payer requirements. </li>\n</ul>\n<ul>\n <li>Partner with clinical, compliance, and operations teams to standardize and continuously improve documentation practices across all markets. </li>\n</ul>\n<ul>\n <li>Align documentation workflows with quality performance and risk capture goals, reducing gaps between clinical care delivery and coded outcomes. </li>\n</ul>\n<ul>\n <li>Implement data validation and quality assurance processes to enhance coding accuracy and protect revenue cycle integrity. </li>\n</ul>\n<p> </p>\n<p><strong>Provider Education & Clinical Integration</strong> </p>\n<ul>\n <li>Develop and implement physician and clinician education programs on coding best practices, CDI, and performance incentives. </li>\n</ul>\n<ul>\n <li>Conduct targeted training for providers with identified coding or documentation gaps, ensuring alignment with risk adjustment accuracy goals. </li>\n</ul>\n<ul>\n <li>Build strong partnerships with medical leadership to embed quality, documentation, and risk capture into clinical workflows and culture. </li>\n</ul>\n<p> </p>\n<p><strong>Operational Integration & Organizational Design</strong> </p>\n<ul>\n <li>Consolidate quality, risk adjustment, and documentation functions under a unified operating model, eliminating silos and ensuring coordinated execution. </li>\n</ul>\n<ul>\n <li>Design and implement an integrated governance and accountability structure across all three functions. </li>\n</ul>\n<ul>\n <li>Drive adoption of digitally enabled workflows, AI-assisted coding tools, EHR optimizations, and predictive analytics to enhance operational scalability and efficiency. </li>\n</ul>\n<ul>\n <li>Develop real-time performance dashboards and KPIs to monitor coding accuracy, quality scores, RAF performance, and revenue integrity at the market level. </li>\n</ul>\n<p> </p>\n<p><strong>Risk, Compliance & Regulatory Oversight</strong> </p>\n<ul>\n <li>Ensure full compliance with CMS, HHS, and all applicable regulatory guidelines across risk adjustment, billing, coding, and quality functions. </li>\n</ul>\n<ul>\n <li>Proactively identify and manage operational, financial, and regulatory risks tied to quality and risk adjustment activities. </li>\n</ul>\n<ul>\n <li>Partner with Compliance and Legal to ensure defensible practices, audit-ready documentation, and alignment with Medicare Advantage regulations. </li>\n</ul>\n<ul>\n <li>Manage claim submissions; analyze rejections and develop corrective action plans. </li>\n</ul>\n<p> </p>\n<p><strong>Performance Management & Reporting</strong> </p>\n<ul>\n <li>Establish KPIs and reporting frameworks tied to quality scores, RAF performance, documentation accuracy, and financial outcomes. </li>\n</ul>\n<ul>\n <li>Drive enterprise-wide accountability for results, with clear line-of-sight from team execution to payer and revenue performance. </li>\n</ul>\n<ul>\n <li>Present performance insights and strategic recommendations to executive leadership and payer partners. </li>\n</ul>\n<p> </p>\n<p> </p>\n<h2>Job Requirements</h2>\n<p><strong>Required Qualifications</strong> </p>\n<p><strong>Experience</strong> </p>\n<ul>\n <li>12+ years of progressive leadership experience in healthcare quality, risk adjustment, clinical documentation, or related functions within value-based care environments. </li>\n</ul>\n<ul>\n <li>7+ years in a senior leadership role overseeing teams across coding, billing, quality, or risk adjustment. </li>\n</ul>\n<ul>\n <li>Demonstrated success improving payer quality scores (STARS, HEDIS) and RAF performance at an enterprise or multi-market level. </li>\n</ul>\n<ul>\n <li>Proven ability to consolidate fragmented functions and lead cross-functional transformation and operational change. </li>\n</ul>\n<ul>\n <li>Experience managing payer audits (CMS RADV, OIG) and developing risk mitigation strategies. </li>\n</ul>\n<ul>\n <li>Experience working with Medicare Advantage plans, ACOs, or other risk-bearing entities. </li>\n</ul>\n<p> </p>\n<p><strong>Knowledge & Skills</strong> </p>\n<ul>\n <li>Deep expertise in Medicare Risk Adjustment (MRA), RAF score optimization, HCC coding, STARS, HEDIS, and related quality programs. </li>\n</ul>\n<ul>\n <li>Strong understanding of clinical documentation improvement (CDI) principles and their connection to revenue and compliance outcomes. </li>\n</ul>\n<ul>\n <li>Proficiency with data analytics tools (SAS, Tableau, SQL, or proprietary risk adjustment platforms); experience with AI-driven coding tools and EHR optimization preferred. </li>\n</ul>\n<ul>\n <li>Strong financial acumen, with the ability to forecast revenue, identify performance trends, and optimize risk-adjusted performance. </li>\n</ul>\n<ul>\n <li>Proven ability to engage and influence physicians and clinical teams, including training and performance improvement strategies. </li>\n</ul>\n<ul>\n <li>Demonstrated experience building processes, controls, and performance-driven accountability cultures. </li>\n</ul>\n<p> </p>\n<p><strong>Education</strong> </p>\n<ul>\n <li>Bachelor’s degree from an accredited four-year college or universityrequired; graduate degree (MBA, MHA, MPH, or clinical) preferred. </li>\n</ul>\n<ul>\n <li>Current certification as a medical coder (CPC, CRC, or equivalent) preferred but not required. </li>\n</ul>\n<p> </p>\n<p><u>Sponsorship Statement</u>WellBe does not offer employment-based visa sponsorship for this position. Applicants must be legally authorized to work in the United States without the need for employer sponsorship now or in the future.<u>Drug Screening Requirement</u>As a condition of employment, WellBe Senior Medical requires all candidates to successfully complete a pre-employment drug screening. Ongoing employment may also be contingent upon compliance with the company’s Drug-Free Workplace Policy, which includes random, post-accident, and reasonable suspicion drug testing. The company reserves the right to test for substances that may impair an employee’s ability to safely and effectively perform their job duties.<u>Background Check Statement</u>Employment is contingent upon successful completion of a background check, as permitted by law. As a healthcare organization, WellBe conducts monthly FACIS (Fraud and Abuse Control Information System) checks on all employees. Continued employment is contingent upon satisfactory results of these checks, in accordance with applicable laws and regulations.<u>Equal Employment Opportunity (EEO) Statement</u>WellBe is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected status.<u>Americans with Disabilities Act </u>WellBe Senior Medical is committed to complying with the Americans with Disabilities Act (ADA) and applicable state and local laws. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the job. If you require an accommodation during the application, interview or employment process, please advise Human Resources during the application process.<u>At-Will Employment Statement</u>Employment with WellBe is at-will unless otherwise specified by contract. This job description does not constitute an employment contract.<u>Disclaimer</u>This job description is intended to describe the general nature and level of work 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.</p>",
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