Vicepresidente Asistente de Operaciones de Gestión Premium
Regular
Exempt
GENERAL DESCRIPTION:
Responsible for driving the operational oversight, execution, and continuous improvement of Coding Operations and Risk Adjustment initiatives to ensure regulatory compliance, coding accuracy, and optimal financial performance. Leads core activities, including Risk Adjustment Data Validation (RADV), Comprehensive Health Risk Assessment (CHRA), and related operations to support accurate risk score assignment, data integrity, and alignment with CMS and organizational requirements. Collaborates cross-functionally and with external vendors to enhance operational efficiency, strengthen compliance outcomes, and support corporate objectives tied to revenue optimization and risk adjustment performance.
ESSENTIAL FUNCTIONS:
- Oversees the operational execution of Premium Management and Risk Adjustment initiatives, ensuring compliance with CMS, HHS, OIG, and internal regulatory requirements.
- Leads and monitors RADV, CHRA, medical record review, and diagnosis coding operations to ensure data accuracy, coding integrity, and appropriate risk score assignment.
- Develops, implements, and monitors operational processes, corrective action plans, and compliance initiatives to improve coding accuracy, audit readiness, and operational performance.
- Collaborates with internal departments, IPA groups, and external vendors to ensure alignment with contractual obligations, operational goals, and risk adjustment performance expectations.
- Monitors operational reports, coding inventories, audit findings, referrals, and vendor performance metrics to identify trends, risks, and improvement opportunities.
- Supports the implementation and validation of operational systems, platforms, and workflow enhancements related to Premium Management and Risk Adjustment activities.
- Supports special projects and strategic operational initiatives, including CMS reporting, Model of Care (MOC), Home Visit Programs, and other departmental initiatives assigned by leadership.
ADDITIONAL FUNCTIONS:
- Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave according to the policies, standards, norms, and procedures of the Company.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS
Education and Experience: Master Degree in Health Administration, Business Administration, Nursing, Public Health, Health Information Management, or related field required. Minimum of six (6) years of progressive experience in Risk Adjustment, Premium Management, Healthcare Operations, Coding Compliance, or related operational areas within healthcare or managed care environments required. Experience with CMS Risk Adjustment, RADV, CHRA operations, and regulatory compliance initiatives required. Minimum of three (3) years of leadership or supervisory experience is required.
OR
Education and Experience: Bachelor Degree in Health Administration, Business Administration, Nursing, Public Health, Health Information Management, or related field required. Minimum of eight (8) years of progressive experience in Risk Adjustment, Premium Management, Healthcare Operations, Coding Compliance, or related operational areas within healthcare or managed care environments required. Experience with CMS Risk Adjustment, RADV, CHRA operations, and regulatory compliance initiatives required. Minimum of five (5) years of leadership or supervisory experience is required.
“Proven experience may be replaced by previously established requirements.”
Certifications / Licenses: Health Information Management (HIM) credentials as apply: Registered Health Information Administrator (RHIA), or Certified Coding Associate (CCA), or Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician (CCS-P), or Medical Billing certifications are preferred.
Other: Knowledge of CMS regulations, processes, and quality measure frameworks (e.g., Star Ratings, HEDIS). Knowledge and understanding of ICD10 guidelines and CMS HCC Payment Model.
Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Advanced (comprehensive, writing and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
