Director Medicare and Medicaid Risk Adjustment

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 05, 2026
Responsible for supporting programs through the end-to-end processes of data management and data submissions. This will be accomplished through designing, building and automating reporting analysis and modeling by utilizing a variety of systems. Essential Functions -Perform analysis and reporting activities relating to: risk score calculation, claims/encounters data submission, chart review programs, audits, and related performance metrics. -Participate in the development of requirements, testing and refinement of the underlying data and systems. -Collaborate with other business units to deliver reports/updates on underlying data and systems as used by the Risk Adjustment team. -Analyze data flow and data integrity to identify areas for improvement. -Operate risk adjustment analytic vendor platforms to assist with intervention tracking, monitoring, analysis and reporting of diagnosis codes that drive risk score calculations. -Work cross-functionally across multiple departments to design and develop financial dashboards, KPIs, and models to identify and track profit/loss and ROI trends. Education Bachelor's Degree required (experience can be considered in lieu of a degree) Master's degree preferred Licensure Certified Risk Adjustment Coder (CRC) or the equivalent coding accreditation preferred Experience 5+ years in a leadership role for Medicare Advantage and Medicaid risk adjustment is highly preferred 8-10+ years of experience in risk adjustment programs required At least 5-7 years of experience managing others is preferred Knowledge, Skills, and Abilities Experience with predictive modeling software required. Subject Matter Expert on Medicare Advantage encounter data submissions Advanced SQL and or SAS programming skills required. Understanding of healthcare claims coding practices required Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value. Bring fresh ideas forward by listening to and working with employees and the people we serve. Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner. Strong, demonstrated track record of an ability to execute on time, on budget, and on scope. Strong aptitude for technology-based solutions. Ability to inject energy, when and where it's needed. Current in healthcare trends. Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be." Ability to develop, introduce, defend, and gain support for a new ideas and approaches. Excellent leadership skills and leadership track record. Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required. Ability to view the long-range trends and cycles of the business and industry and see the "big picture." Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions. Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy. Excellent interpersonal skills, including the ability to influence others at all levels of an organization. Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Unquestionable integrity. Working Conditions This is a remote role that can be done from most US states Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.