Director, Risk Adjustment Coding & Revenue Cycle Operations

What You’ll Do 

Position Summary

We are seeking an experienced Director of Medicare Risk Adjustment and Revenue Cycle Operations to lead our revenue cycle operations in a dynamic, growth-stage environment. This critical leadership role will oversee all aspects of Medicare Advantage billing, coding accuracy, and risk adjustment processes under our full-risk primary care model. The ideal candidate will bring deep expertise in value based care and a proven track record of building scalable systems that drive financial performance while ensuring regulatory compliance.

Responsibilities

Revenue Cycle Leadership

·      Direct all Medicare Advantage billing operations, ensuring accurate and timely claim submission and resolution under global capitation arrangements

·      Develop and implement comprehensive billing and coding strategies that optimize revenue capture while maintaining compliance with CMS regulations

·      Work closely with operations and clinical operations to optimize processes and ensure efficient revenue cycle management

Risk Adjustment and HCC Coding

·      Lead and manage the Medicare Risk Adjustment program, ensuring alignment with organizational goals and regulatory requirements

·      Develop and implement strategies to improve accuracy in the capture of patient conditions. 

·      Collaborate with clinical teams, operational leaders, and quality departments to identify opportunities for improvement and address challenges within the risk adjustment process.

·      Stay current with industry trends, CMS regulations, and best practices related to Medicare Risk Adjustment and coding.

·      Establish quality assurance programs to ensure diagnosis coding accurately reflects patient acuity and complexity

·      Develop and monitor key performance indicators for risk adjustment accuracy, including risk adjustment factor (RAF) trends and HCC capture rates

Compliance and Audit Management

·      Maintain expert knowledge of Medicare Advantage regulations, CMS coding guidelines, and RADV audit requirements

·      Design and oversee internal audit programs to proactively identify and remediate coding accuracy issues

·      Ensure compliance with all federal and state regulations governing Medicare billing and risk adjustment

·      Manage external audit responses and work with legal/compliance teams on regulatory inquiries

Team Development and Scaling

·      Build, mentor, and scale a high-performing team of billing and coding professionals to support company growth

·      Establish training programs and competency standards for coding staff, including ongoing education on ICD-10, CPT, and HCC coding

·      Create workflows and documentation standards that can scale with organizational expansion

Strategic Partnership

·      Collaborate with finance leadership to forecast revenue, analyze payer performance, and support financial planning

·      Partner with clinical operations to align documentation improvement initiatives with quality care delivery

·      Work with technology teams to optimize billing systems, coding tools, and data analytics capabilities

·      Serve as subject matter expert to senior leadership on all matters related to Medicare reimbursement and risk-based contracting

What You’ll Bring

Knowledge, Skills, and Abilities

• 8+ years of progressive experience in Medicare billing and coding, with at least 4 years in leadership roles
• Demonstrated experience with global capitation and risk-based payment models
• Deep knowledge of CMS regulations, RADV audit processes, and Medicare compliance requirements
• Professional coding certification (CRC, CPC, RHIA, RHIT, or equivalent) strongly preferred
• Proven ability to build and scale operations in a high-growth environment
• Experience implementing billing systems and revenue cycle technology platforms
• Strong analytical skills with ability to translate data into actionable insights
• Proven ability to lead cross-functional teams and collaborate effectively with clinicians and operational leaders.
• Strategic thinking with ability to balance growth objectives with compliance imperatives
• Exceptional leadership and team-building capabilities in fast-paced settings
• Outstanding communication skills with ability to influence cross-functional stakeholders and present to senior leadership
• Process optimization mindset with track record of driving operational efficiency
• Adaptability and comfort with ambiguity inherent in early-stage companies
• Results-oriented approach with strong accountability for financial and quality outcomes

Education, Experience, Licensure, or Certification Requirements

• Bachelor's degree in Health Information Management, Healthcare Administration, Business Administration, or related field; advanced degree preferred

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.