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Department: Risk Adjustment & Quality Product Operations

Reports to: VP of Product

Position Summary

The Director of Risk Adjustment and Quality leads the strategy, execution, and optimization of risk adjustment and quality initiatives for our SaaS platform serving Medicare Advantage, provider organizations, and payer markets. This role ensures our platform delivers accurate risk scoring, quality measure tracking, and regulatory compliance while supporting clients’ value-based care and financial performance goals.

Key Responsibilities

Own the risk adjustment and quality product roadmap for Medicare Advantage, provider organizations, and commercial payer clients. Lead the development of HCC coding, suspecting, recapture tracking, and gap closure modules within the platform. Oversee analytics, reporting, and client enablement programs focused on risk adjustment accuracy and quality measure performance (HEDIS, STAR Ratings, CAHPS, etc.). Ensure compliance with CMS guidelines, NCQA standards, and other regulatory requirements specific to Medicare Advantage and commercial risk programs. Partner with Product, Engineering, and Data Science teams to deliver scalable, high-performing SaaS solutions supporting MA plans, provider groups, and health plans. Work directly with client leadership teams to translate regulatory and business requirements into actionable platform configurations and reporting strategies. Provide subject matter expertise on CMS file formats (BCDA, CCLF, EDGE) and value-based care models including ACO REACH, MSSP, and commercial risk arrangements. Lead internal teams including clinical coders, quality analysts, and client success staff focused on risk and quality performance improvement. Analyze and report on key KPIs including RAF score accuracy, gap closure rates, and STAR metric performance, driving continuous improvement strategies. Monitor industry trends, regulatory updates, and competitor activity to inform product and business strategy.

Qualifications

Bachelor’s degree in Healthcare Administration, Public Health, Data Science, or a related field; Master’s preferred. 8+ years of experience in Medicare Advantage, risk adjustment, and quality improvement within a payer, provider, or SaaS environment. Proven leadership experience overseeing risk adjustment and quality programs, including team management and cross-functional collaboration. Deep understanding of Medicare Advantage program requirements, including HCC coding, STAR ratings, HEDIS measures, CAHPS, and VBP models. Experience with payer-provider collaboration and managing risk programs across different organizational structures. Familiarity with healthcare data formats: FHIR, HL7, BCDA, CCLF, EDGE files, and claims data. Exceptional communication, client-facing, and presentation skills.

Preferred Skills

Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC). Experience deploying AI or machine learning solutions for risk adjustment or quality gap closure. Strong understanding of data integration workflows supporting payers, providers, and Medicare Advantage plans.

Lightbeam Internal Use Only

Position Security Classification

CRITERIA: POSITION RISK LEVEL

High Risk (if any of these are true)

Access to Restricted information, including PHI and PII

Elevated access privileges

Access to the Security Infrastructure

Medium Risk

Access to Confidential, but not to Restricted information

Low Risk

Access to Unclassified information only

Director of Risk Adjustment and Quality : High

CRITERIA: SECURITY ROLES & RESPONIBILITIES

Security Roles & Responsibilities

Approve security-related changes Execute security-related changes Not applicable

Policy/procedures for Lightbeam

Cyber Security Incident Response (CSIRT) team

Director of Risk Adjustment and Quality: Not Applicable

SECURITY ROLE-SPECIFIC TRAINING

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