Assistant Vice President (AVP), Risk Adjustment

Responsible for leading enterprise development of the Risk Adjustment strategy and operation for Risk Revenue Program to meet business goals and improve market competitiveness for each segment: Medicare Advantage HMO/PPO, Experience Health HMO, D\-SNP, ACA u65, and ACA small groups.Medicare Advantage \& ACA Marketplace

Single‑State Health Plan

At Blue Cross NC, we’re making health care better for all – by listening deeply, challenging what’s possible, and putting care at the heart of everything we do. Join a purpose‑driven team where ideas spark change, growth is encouraged, collaboration fuels impact, and you’re supported with the flexibility and trust to do meaningful work.

Position Overview

The Assistant Vice President (AVP) of Risk Adjustment provides strategic, operational, and financial leadership for all Risk Adjustment activities across Medicare Advantage and ACA Marketplace lines of business within a single\-state health plan. This role is accountable for the design, execution, and continuous optimization of end‑to‑end Risk Adjustment programs—ensuring accurate revenue capture, regulatory compliance, and sustainability of performance in a dynamic regulatory environment.

Reporting to \[SVP/VP, Finance / Risk / Population Health], the AVP serves as a key enterprise leader and strategic partner to Finance, Actuarial, Clinical, Network, Compliance, Analytics, and Operations teams. The role combines deep technical expertise with people leadership and enterprise influence.

What You’ll Do

Strategic Leadership

• Set and execute a multi\-year Risk Adjustment strategy for Medicare Advantage and ACA Marketplace aligned to organizational growth, quality, and financial performance.
• Anticipate and prepare for CMS and HHS regulatory changes, including RADV, V28, HCC model changes, audit trends, and policy updates.
• Serve as the executive subject matter expert on Risk Adjustment performance, risk score accuracy, and revenue impacts.

Program \& Operational Oversight

• Lead all Risk Adjustment functions, including:

+ Provider documentation and coding strategy

+ Provider education and engagement

+ Retrospective and prospective chart review programs

+ Data capture, submission, and reconciliation

+ Audit readiness and response (RADV / HHS audits)

• Ensure strong internal controls and processes supporting compliance, accuracy, and operational efficiency.
• Oversee vendor strategy, performance management, and contract optimization.

Financial \& Performance Accountability

• Partner with Finance and Actuarial teams to forecast Risk Adjustment revenue, assess performance drivers, and quantify financial outcomes.
• Monitor and report on risk score trends, coding completeness, coding accuracy, and return on investment (ROI).
• Drive continuous improvement through data\-driven insights, analytics, and performance dashboards.

Clinical \& Provider Collaboration

• Collaborate closely with Quality Management/STARS team, Medical Management, Population Health, and Clinical Informatics to integrate Risk Adjustment into care models and workflows.
• Build and sustain strong relationships with provider groups, medical practices, and clinical leaders across the state.
• Champion provider\-friendly, compliant documentation strategies that support quality care and accurate risk capture.

People \& Culture Leadership

• Lead, mentor, and develop a high\-performing Risk Adjustment team, fostering accountability, innovation, and continuous learning.
• Establish clear goals, performance expectations, and succession planning.
• Promote a culture of integrity, transparency, and cross\-functional partnership.

What You’ll Bring

• Bachelor’s degree required; Master’s degree (MBA, MPH, MHA, or similar) strongly preferred.
• 10\+ years of progressive experience in Risk Adjustment within a health plan, with direct experience in:

+ Medicare Advantage Risk Adjustment

+ ACA Marketplace Risk Adjustment

• 5\+ years of people leadership experience managing managers and/or senior leaders.
• Deep knowledge of:

+ CMS HCC and HHS Risk Adjustment models

+ RADV audits and compliance requirements

+ Coding guidelines (ICD‑10‑CM) and documentation standards

• Proven ability to partner with executive leadership and influence enterprise\-wide outcomes.
• Strong analytical, financial, and communication skills.

Bonus Points

• Experience leading Risk Adjustment for both Medicare and ACA in the same organization.
• Prior experience with
single\-state or regional health plans.
• Demonstrated success navigating regulatory change and model transitions.
• Experience integrating Risk Adjustment into value\-based care or population health strategies.
• Vendor management and RFP experience.

What You’ll Get

• Opportunity to shape and lead Risk Adjustment strategy at an enterprise level.
• High visibility role with executive partnership and influence.
• Mission\-driven organization focused on affordability, quality, and community impact.
• Competitive compensation, incentive opportunity, and comprehensive benefits.

Our Hybrid Flex Workplace

Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in\-person connection – that supports a workplace that’s flexible, connected, and future focused.

In a Hybrid\-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in\-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market\-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus\*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

Based on annual corporate goal achievement and individual performance.*

$210,268\.00 \- $336,430\.00Skills

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