Company and Role Description

Antidote Health’s mission is to redefine healthcare by providing affordable, high-quality, and accessible care and insurance products. As the Head of Risk Adjustment, you will lead our risk adjustment strategy, operations, and analytics to ensure compliance, accuracy, and financial sustainability. You will collaborate with cross-functional partners in Clinical, Provider Network, Product, Finance, Compliance, and Data Science to design and execute a best-in-class program that ensures complete and accurate risk capture, supports value-based care, and enables equitable outcomes for our members.

Key Responsibilities

Strategic Leadership & Program Management

• Define and execute Antidote’s risk adjustment strategy on the ACA Marketplace.
• Lead and manage the Risk Adjustment process with finance, product, clinical, marketing, and operations, fostering a culture of accountability, innovation, collaboration, and continuous improvement.
• Develop and oversee programs to maximize risk score accuracy, including chart reviews, suspecting, and gap closure initiatives.

Risk Adjustment Operations & Analytics

• Partner with internal teams and external partners to forecast revenue, identify coding opportunities, and measure program performance.
• Oversee end-to-end risk adjustment workflows across prospective and retrospective processes, including vendor management.
• Develop dashboards, KPIs, and reports for executives to track performance and compliance.

Compliance & Quality Assurance

• Ensure adherence to CMS, HHS, state-specific risk adjustment guidelines and monitor regulatory changes and proactively update processes.
• Oversee processes for accurate and timely submissions (e.g., EDGE server submission).
• Collaborate with Compliance and Legal to prepare for RADV audits, respond to regulatory inquiries, and mitigate compliance risks.

Cross-Functional Collaboration

• Work closely with other teams to ensure accurate coding and data alignment.
• Partner with Product and Engineering to design and enhance risk adjustment technology, including NLP/AI-enabled coding and chart retrieval solutions.
• Engage with Finance leaders to forecast and reconcile risk-adjusted revenue.

Qualifications & Skills

Required:

• Bachelor’s degree in Analytics, Public Health, Business, or a related field (Master’s preferred).
• 7+ years of experience in leading risk adjustment processes. .
• Demonstrated expertise in CMS-HCC, RxHCC, and HHS-HCC risk adjustment models.
• Experience managing prospective and retrospective risk adjustment programs.
• Strong data analytical skills
• Knowledge of regulatory requirements (CMS, HHS, NCQA, ACA).
• Excellent leadership, communication, and stakeholder management skills.
• Prior leadership experience within Medicare Advantage, Medicaid Managed Care, or ACA health plans.

Preferred:

• Experience with EDS submissions, EDGE server data validation, and encounter data management.
• Familiarity with medical coding (ICD-10-CM, CPT, HCPCS) and clinical documentation improvement (CDI).
• Ability to leverage technology (AI, NLP, machine learning) to improve risk adjustment performance.
• Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or similar credential preferred