AIDS Healthcare Foundation

Director of Risk Adjustment

US-CA-Los Angeles
Req No
Managed Care
Regular Full-Time



Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees?


If so, AIDS Healthcare Foundation is the place for you!

Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.


AHF’s core values are to be:

• Patient-Centered

• Value Employees

• Respect for Diversity

• Nimble

• Fight for What’s Right


STILL INTERESTED? Please continue!


AIDS Healthcare Foundation is seeking a full-time, Director of Risk Adjustment to assist at our Managed Care Office located at the following address:


1001 North Martel Avenue

Los Angeles, California 90046


Hours of Operations:  Monday - Friday, 8:30am-5:30pm


Job Summary: 


The Director of Risk Adjustment (DRA) Program is responsible for projecting and integrating the Mission and Core Values of the organization as well as AHF’s Management Philosophy of mission driven, fairness, learning, hands-on, accountability and tenacity in the leadership of the Risk Adjustment Management Department.


Risk Adjustment Program has a significant impact on identifying accurate data elements that contribute to the revenue cycle of the AIDS Healthcare Foundation’s Medicare Advantage Part D Special Needs Plans for persons with HIV/AIDS.   The DRA responsible for leading the enterprise-wide Risk Adjustment program and ensuring that risk exposures and opportunities are identified with the key objective of optimizing revenue integrity and accuracy. This position also has responsibility for retrospective and prospective strategies and the internal Risk Adjustment team, and works with the prospective team to drive enhanced physician engagement and member interaction. The Medicare Risk Adjustment Director will have accountability to the Chief of Managed Care and Managed Care senior leaders of the PHP health plans.   The DRA adheres to the AHF-PHP Compliance Program, including following all regulatory and AHF policy requirements.


The DRA is responsible for ensuring that AHF’s  risk adjustment programs are compliant with Centers for Medicare and Medicaid Services (CMS) and State and federal regulatory requirements, implements and monitors AHF’s HCC/RAF strategies across all applicable product lines, ensures cost effective oversight for the entire life cycle of HCC/RAF scores from assessment to submissions to CMS to response to CMS return files to ensure complete and accurate transmissions.                                                                 


Primary duties:

  • Accountable for the operating result and ultimate outcome of Risk Adjustment program and provides strategic direction for a high functioning risk adjustment team responsible for all risk adjustment plan execution.
  • Provide leadership and guidance for overall Risk Adjustment programs as well as identifying and application of best practices to ensure efficacy and accuracy of risk adjustment programs. Develop and regularly update risk adjustment policies and procedures.
  • Facilitate relationships of the cross-functional and integrated process across the organization and with key business leaders to develop programs and streamline and leverage risk adjustment related activities including prospective services (e.g., member and provider engagement, and in-home/supplemental assessments) and retrospective activities.
  • Provide reporting and analysis of revenue results to assist product development strategy and bid support.
  • Plan, implement and provide oversight to Medicaid based Risk Adjustment programs as rolled out be states within the health plan territories.
  • Maintains expert knowledge of principles and methods of planning, directing and maintaining compliance with risk adjustment standards. HMO, Medi-Cal/Medicaid, Medicare and insurance programs relating to risk adjustment practices and processes including state and federal standards and regulations for member and provider rights and responsibilities.
  • Ability to manage major projects and/or programs that require strict and time sensitive deadlines.
  • Effectively communicates in both written and oral fashion, as well as possessing a high level of attention to detail.  
  • Ability to confidently make presentations to internal and external audiences and represent AHF-PHP in a positive manner.
  • Collaborates and communicates well to medical providers concerning RA program and effective documentation of member diagnosis and medical care.
  • Communicates and presents complex data and concepts in a manner that is easily understandable to a wide range of audiences.
  • Model and monitor risk adjusted revenue by line of business and review cost and utilization trends to understand impact on revenue.
  • Drive the preparation of analysis and reporting of ongoing revenue trends across the health plans. Reports to the Chief on a monthly basis the findings of analysis and actions.
  • Develop strategic plans by determining goals, metrics, timeframes and appropriate resources to drive the achievement of risk adjustment programs and value the contribution of those initiatives.
  • Oversee risk adjustment related activities and compliance, including but not limited to HCC programs, Risk Adjustment Data Validation (RADV), enrollment, and special status and encounter data to ensure achievement of accurate, timely, and expected outcomes.
  • Collaborates with IT Data Team to assure accurate, timely and complete submissions to CMS and other state or federal agencies.
  • Oversee and manage external vendor relationships, including audits, for performance and compliance.
  • Oversee the design and development of risk adjustment data extracts and warehouses that are distributed to internal business partners.
  • Monitor department budget vs. actual financial results, conduct variance analyses of variance, and prepare variance summaries.
  • Identify opportunities for automation in processes and opportunities to integrate additional data sources allowing for new functionality.
  • Prepare and maintain documentation and controls for routine procedures.
  • Participate in departmental process improvement initiatives that involve designing, adjusting, and documenting work processes to ensure that predictable and repeatable success is achieved through best practice.
  • Maintain high regard for member privacy in accordance with AHF PHP/PHC privacy policies and procedures.
  • Maintain knowledge of all relevant legislative and regulatory mandates and ensure that all activities are in compliance with these requirements.
  • Interprets state and federal regulations and laws and contractual obligations and translate them into policies, procedures, standards and guidelines.
  • Provide effective leadership to staff (direct and indirect) with particular attention to effective recruitment, mentoring and ongoing performance.
  • Plan, assign, supervise and evaluate the work of others and monitor goals, objectives, deadlines and priorities.
  • Holds staff accountable to contractual, accreditation and regulatory requirements.  Implements corrective action plans immediately in order to avoid material impact on plan performance monitoring.
  • Perform other duties as assigned.


To perform this job successfully, an individual must be able to satisfactorily perform the essential duties.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Education and/or Experience

  • Bachelors Degree from an accredited college/university.
  • Preferred field of study: business, math, finance, economics, actuarial science, healthcare.
  • Position requires at least 2 years of manager or director level experience with Medicare Advantage
  • Risk Adjustment.
  • Experience with HHS Commercial Risk Adjustment programs preferred.
  • Experience and familiarity with actuarial, finance and/or operational activities of a health plan.
  • Knowledge of Correct Coding Initiative (CCI). Certified in medial coding a plus.
  • Proven project management experience.
  • Demonstrated success in improving Risk Adjustment measures.
  • Demonstrated success working in a matrix environment.
  • Demonstrated success leading cross-functional teams.
  • Unrestricted Driver License and vehicle insurance


Computer/Software Skills & Abilities

To perform this job successfully, an individual should have knowledge of standard business software, including but not limited to:







This level of skills is necessary in order to use and create a variety of templates, complex tables, merges; manage table data, sort and filter merges, and also perform basic work with existing Macros. A person with this level of skills is able to customize toolbars, import and insert graphs, embed Excel data, and elaborate reports.

The person has the skills to

·   Work with sections, create templates, use styles, and customize them.

·  Create and format complex tables, and manage table data.

·  Create Mail Merges, sort and filter them.

·  Customize Toolbars.

·  Insert graphic elements.

·  Run and record Macros.

·  Format documents, control page and document appearance, paginate and link table of contents.

Mail merge, generate envelopes, etc.



This level of skills is required to work with multiple worksheets, filter data, use integrate functions, and manipulate databases.  With this level of skills, a person understands the concepts of databases and is able to work with charts and to use the list management capabilities of Excel.

The person has the skills to

·       Create, modify, and format charts.

·       Use graphic objects to enhance worksheets and charts.

·       Filter data and manage a filtered list.

·       Perform multiple-level sorting, use sorting options, and design considerations.

·       Use mathematical, logical, statistical, and financial functions.

·       Group and dissociate data and perform interactive analysis.

·       Create and modify some Macro commands.



This level of skills is desired to design, create, and modify databases, tables, queries, forms, and reports.  A person with this level of skills understands the different database concepts and structures and is familiar with data validation and indexing techniques

The person has the skills to

·       Plan, conceive, create, save, manage, and maintain a database.

·       Modify a database structure.

·       Generate new records and modify them.

·       Create tables with Table Wizard and in Design View and work with them.

·       Find, edit, filter, and sort records.

·       Create and use Select Queries to view specific records and to perform calculations.

·       Create, use, and customize forms, and reports.

·       Work with Data Access Pages.

Power Point

Intermediate & Advanced

This level of skills is required to customize templates and the PowerPoint environment, and to make a presentation interactive by using hyperlinks and action buttons.

The person has the skills to

·       Create a template and work with a Design template.

·       Work with graphics, animation and multimedia, inserting movies and sound.

·       Work with the Office Suite to create slides from an outline and send slides to Microsoft Word.

·       Customize PowerPoint toolbars and automate the slide production.

·       Use AutoCorrect and the Style Checker.

·       Build interactive presentations, using hyperlinks, creating interactive objects, working with Slide Show options, and using the Meeting Minder.

·       Explore online meetings and broadcast presentations



This level of skill is required to develop process flow charts, organizational charts and incorporating drawings into other documents

The person has the skills to:

·       Create a process flow or organizational diagram and insert it into documents

·       Associate data with the shapes in the diagrams

·       Develop charts that are connected and self- populate from a database.

·       Import and export Word outlines or Visio diagrams into either program

Internet Explorer


This level of skill is required to conduct research, obtain data and connect with work related social networking programs.

The person has the skills to:

·       Conduct data searches

·       Manage internet and intranet sites

·       Update MC websites

·       Utilize social networking sites to expand the sphere of influence of the MC Division.


Language Skills

  • Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or issues. Ability to effectively present information to medical providers, top management or public groups.


Mathematical Skills

  • High mathematical skills required. Ability to apply mathematical principles to practical solutions, using fractions, percentages, ratios, and proportions.


Reasoning Ability

  • Ability to define problems, collect data, establish facts, and draw valid conclusions.



  • Travel locally and in the domestic United States up to 35% of the time


Other Skills & Abilities/Qualifications


  • Ability to successfully work with various levels of professional and non-professional staff.
  • Must be able to work independently and as a part of a team.
  • Knowledge of HIV/AIDS, related medical and patient care issues and concerns in diverse populations a plus.


 We at AIDS Healthcare Foundation believe that each individual is entitled to equal employment opportunities without regard to race, color, creed, gender, sexual orientation, gender identity, marital status, national origin, age, veteran status or disability. The right of equal employment opportunity extends to recruiting, hiring selection, transfer, promotion, training and all other conditions of employment.



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