Director of Risk Adjustment & Coding - Ontario, California

    • Ontario, CA

Position Description

North American Medical Management, California, Inc. (NAMM California) partnered with OptumHealth in 2012. NAMM California and OptumHealth share a common goal of bringing patients, physicians, hospitals and payers closer together in the mission to increase the quality, efficiency and affordability of care. NAMM California is a part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. NAMM California develops and manages provider networks, offering a full range of services to assist physicians and other providers in supporting patient care coordination and their managed care business operations. For over 18 years, NAMM California has been an innovator in health care with a track record for quality, financial stability, extraordinary services and integrated medical management programs. NAMM California is well positioned to continually invest in its infrastructure and systems for the benefit of its provider clients and to accommodate the impending changes that will come forth from healthcare reform.

The NAMM California provider clients represent a network of almost 600 primary care physicians and over 3,000 specialists and work with the premier hospitals in their respective markets.



The position leads strategic vision for NAMM Risk Adjustment activities, drives operational processes, systems and facilitates provider/staff risk adjustment educational training for NAMMs Risk Adjustment and Coding program. The Risk and Coding department supports 90,000 senior members, a network of over 400 PCPs, 2000 Specialists and collaboration with over a dozen contracted hospitals.

If you are located in San Bernardino, Los Angeles, or Orange Counties in California , you will have the flexibility to telecommute as you take on some tough challenges.

Primary Responsibilities:

  • Required to work in a matrixed environment and responsible for all Risk Adjustment related activities to support the Care Delivery Organization including goal setting, business planning and contracting efforts
  • Responsible for managing 20 FTEs within Risk & Coding Dept Responsibilities to include:
    • Sets team direction, resolves problems and provides guidance to members of team
    • Design annual coding programs including but not limited to: physician outreach, physician-education, goal setting, and forecasting, plus maintain a robust quality control program for coding accuracy
    • Provides key input to other departments responsible for coding education, physician outreach, nurse practitioner program, and home assessments
    • Monitor productivity and implement solutions to optimization coding department and vendor productivity
    • Attend inter-departmental meetings related to HCC coding/RAF score as well as key point person with Healthplan Coding Department contacts
  • Primary accountable contact for 10+ vendor contracts supporting risk adjustment efforts including contract negotiation, setting goals and tracking performance, and analyzing program ROI
  • Accountable to collaborate with 13 managed care senior health plans risk adjustment activities, audits, including but not limited to RADV
  • This individual is the primary contact for Optum Clinical Performance team as it relates to risk adjustment activities (planning, tracking and program development/participation)
  • Actively manage and optimize the end-to-end risk adjustment processes for NAMM and identify risks and opportunities associated with current processes
  • Analyze business process information (e.g., metrics; analytics) to identify key issues, trends, and potential root causes (e.g., training issues; lack of understanding by user community) that point to improvement opportunities
  • Travel to physician offices and IPA locations to provide education and communicate information related to the Risk Adjustment program
  • Oversee, coordinate, or perform data mining and data-driven analysis to forecast/evaluate the performance of the risk adjustment program and refine annual risk adjustment program strategies to achieve optimal performance. Incorporate data-driven analysis into the risk adjustment processes
  • Adapts departmental plans and priorities to address business and operational challenges


You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:
  • B.S. Degree
  • 5+ years' experience of Managing Staff
  • 5+ years' experience with Medicare Risk adjustment
  • Intermediate Excel skills, PowerPoint (MS Suite)

Preferred Qualifications:
  • Experience with Strategic analysis and direction
  • Vendor Relationship Management experience
  • Experience with Medical Coding
  • Work experience with physicians within an IPA or a Medical Group
  • Business Process Improvement a plus
  • Data mining and data-driven analysis experience


Careers with Optum. We built an entire organization around one giant objective; make the health system work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on an elite team. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Director of Risk Management and Coding, Risk management, Risk adjustment, Medicare Advantage, IPA, Managed Care, Vendor management, Process Improvement, PowerPoint, Excel, Ontario, CA, California, San Bernardino, Las Angeles, Orange, telecommute, telecommuter, telecommuting, work from home, work at home, travel


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