Provide strategic management oversight in designing, implementing, directing, and monitoring the Alliance’s Risk Adjustment Department functions.
Direct the Risk Adjustment Department, act as a subject matter expert, and provide executive-level advice and guidance on coding and risk adjustment methodologies and overall business operations.
Direct, manage, and supervise Risk Adjustment Department staff
Oversee the enterprise sales cycle, pipeline and progress for the Clinical Operations, Risk Adjustment and Quality Divisions.
Lead go-to-market strategy and sales execution for Clinical Operations solutions, including Utilization Management, Care Management, and Appeals & Grievances, articulating value to health plan operational and clinical buyers.
Drive pipeline development and revenue growth for Risk Adjustment offerings (both retrospective and prospective SaaS/BPaaS models) across Medicare Advantage, ACA, and Managed Medicaid markets.
HealthEdge is dedicated to meeting the business’s annual and long-term financial objectives, ensuring ongoing customer satisfaction, and increasing HealthEdge brand awareness and market visibility. They are committed to building an environment and culture that supports the diverse representation of our teams.
Oversee and/or perform an accurate medical record review for all RISK.
Conduct training related to ,RISK, platform usage, update any training materials, and function as RISK SME.
Manage RISK coding projects when needed- including project status and completing chart reviews for coding projects as needed.
Reveleer delivers a unified platform spanning risk adjustment, quality improvement, clinical intelligence, and member management for health plans and provider organizations navigating the complexity of value-based care. They are trusted by 80+ customer organizations nationwide and work to advance care quality, strengthen documentation integrity, and sustain operational readiness.
Own the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
Design and oversee a robust audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation.
Clover Health aims to improve the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They are a mission-driven team of individuals, who are passionate about solving healthcare's most complicated problems, and strive to put members first.
Accountable for driving market-wide quality and savings targets by supporting the development of strategies and overseeing the execution of core ACO transformation strategies.
Lead a team of Practice Transformation Specialists (PTS) to ensure high-quality service delivery within the Explorer Market.
Provide frontline feedback to the Program Director to help build and refine the service delivery model while standing up the program.
Aledade empowers independent primary care practices to deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Lead the development of predictive models to identify care gaps and design segmentation strategies for high-impact interventions.
Translate analytical findings into actionable recommendations and establish frameworks to measure the effectiveness and ROI of HEDIS initiatives.
Design enterprise performance dashboards, ensure data quality, and partner with cross-functional teams to align analytics with business needs.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association focused on improving the health and well-being of its members and their communities. It is voted one of the best places to work in PA, fostering a flexible and supportive culture that prioritizes employee health, wellbeing, and community volunteering.
Negotiate MA & Medicaid value-based care contracts with prospective payer partners.
Collaborate with Senior Leadership to qualify and source market growth and expansion for multi-year risk arrangements.
Build and manage relationships with payers and other key stakeholders to resolve issues and optimize performance.
Aledade empowers independent primary care practices to deliver better care to their patients and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country, operating with a collaborative, inclusive, and remote-first culture.
Co-create with customers working directly with medical device commercial leaders, market access executive stakeholders to ideate, scope, and execute analytical deliverables that address their highest-priority commercial questions.
Drive cross-functional initiatives serving as the connective tissue between Sales, Product, Engineering, and Customer Success; own high-priority projects end-to-end, ensuring alignment, clear accountability, and on-time execution across teams.
Leverage the analytical engine for medical device clients pulling, transforming, and synthesizing data across price transparency, claims, and partner datasets to surface commercial-grade insights for both implantable and non-implantable device portfolios.
Turquoise Health is a Series C price transparency platform for finance leaders across healthcare. They power price transparency for 300+ enterprise organizations and are building the infrastructure for a more open, efficient healthcare marketplace. They are a remote-first, US-based team that values transparency, empathy, inclusivity, creativity, and ownership.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
Lead and inspire a team of Patient Support Specialists.
Establish and refine team KPIs related to outreach volume and scheduling conversions.
Partner with clinical, engagement, and product teams.
Zócalo Health is the first tech-driven provider built specifically for Latinos, by Latinos. They are developing a new approach to care that is designed around shared and lived experiences and brings care to the community. The company was founded in 2021 and is backed by leading healthcare and social impact investors.
Lead and manage a team of Regional Directors, providing coaching and performance feedback.
Oversee the delivery of consulting services to specialty provider practices.
Develop and implement strategies to support the needs of specialty customers.
The company is looking for a Lead Director, Managed Care. They value creating an inclusive culture by empowering employees to bring their unique and diverse selves to work.
Accountable for the development and maintenance of clinical and reimbursement policies, ensuring alignment with CMS regulations.
Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and national coding guidelines.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies.
Clover Health focuses on improving the health of its members by leveraging technology and data-driven insights to provide personalized, high-quality care. They aim to empower their members by helping them navigate the complexities of healthcare and live healthier lives and are passionate about making healthcare easier, more affordable, and more accessible for everyone.
Contribute to the design and evolution of BetterHelp’s care models, including workflows and AI-supported experiences.
Support strategic decision-making by identifying gaps, opportunities, and tradeoffs in the current care model.
Analyze clinical, product and operational data and synthesize findings into clear recommendations for stakeholders influencing product, clinical, and business strategy.
BetterHelp's mission is to remove the traditional barriers to therapy and make mental health care more accessible. Founded in 2013, they are now the world’s largest online therapy service with over 30,000 therapists.
Lead population analytics to identify variation in clinical and economic outcomes.
Apply RWE and health economic modeling to prioritize population health initiatives.
Communicate clinical, quality, and economic insights to leadership.
AffirmedRx aims to improve healthcare outcomes by making pharmacy benefits easy to understand and accessible. They are committed to clarity in business practices and use state-of-the-art technology. The company values its team and believes in a culture where people thrive.
Lead a team of business analysts who own data management, operational and value reporting, and ad-hoc data requests for Risk Control.
Set strategy, partner with data science and engineering to deliver productionized models and translate those capabilities into outcomes.
Balance long-term strategic thinking with hands-on execution, defining use-cases, prototyping, and driving change management.
Liberty Mutual strives to create a workplace where everyone feels valued and supported. They build an environment that welcomes diverse perspectives, embedding inclusion in their culture and everyday interactions.
Managing data workflows and analysis in support of the Quality team.
Collaborating on cross-functional projects to embed quality measures into standard operations.
Building high-impact quality analytics and supporting the design of patient outcome metrics.
Aledade, a public benefit corporation, empowers independent primary care, helping practices, health centers, and clinics deliver better care and thrive in value-based care. Founded in 2014, they've become the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Oversee enrollment and billing operations across all Government Programs including Medicare Advantage, Medicare Supplement, CHIP, and ACA products to ensure accuracy and operational performance.
Lead Medicare Advantage appeals and grievances operations to ensure timely, compliant resolution and audit readiness in accordance with CMS requirements.
Drive process improvement initiatives and cross-functional coordination to enhance regulatory outcomes, member experience, and operational efficiency.
Capital Blue Cross is a health insurance company and independent licensee of the Blue Cross Blue Shield Association that promises to go the extra mile for its team and community. It is consistently voted one of the 'Best Places to Work in PA,' fosters a flexible environment prioritizing health and wellbeing, and invests heavily in employee training and continuing education.
Collaborate with stakeholders to design trainings and resources for performance improvement.
Coordinate across field teams for streamlined delivery of resources, including direct consulting.
Operationalize Collaborative Learning Networks by leveraging data insights and standard curriculums.
Aledade empowers independent primary care practices to deliver better care to their patients and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive and remote-first culture.
Participate in client calls alongside clinicians to communicate the latest research findings.
Analyze patient medical records, including data extraction and tracking of lab values.
Research, evaluate, and prioritize treatment options for individual cases.
Private Health Management (PHM) is a clinically sophisticated healthcare navigation firm, specializing in assisting clients to obtain the best care and outcomes when facing serious and complex medical conditions. They believe everyone should benefit from the latest science-backed insights.
Oversee the Commercial segment within the Strategic Payer Partnerships team ensuring performance goals and objectives are met.
Collaborate with Executive Leadership to shape Aledade's strategy for value-based contracting on behalf of independent primary care practices.
Lead, direct, and evaluate a team of senior leaders ranging from Manager to Sr. Director.
Aledade empowers independent primary care practices to deliver better care to their patients and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Research and document new payment integrity concepts by analyzing medical policies, billing regulations, and reimbursement logic.
Translate complex billing rules into precise technical specifications for automated claim auditing algorithms.
Conduct hands-on data analysis using Microsoft Excel to explore datasets and quantify savings potential for clients.
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and handle over 12 million prior authorization requests annually. The Coherenauts who succeed here are empathetic teammates who are candid, kind, caring, and embody their core values and principles.