Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Risk Adjustment Operations Leader

Director and Equivalent
2103B Requisition #
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Responsible for leading all EmblemHealth efforts related to the development and execution of provider risk adjustment programs across all 3 business lines (Medicare, Medicaid, and Commercial ACA). Direct a team of provider risk adjustment engagement specialists; drive provider intervention strategies that will produce successful risk adjustment outcomes related to risk scores and improved prevalence of accurate and complete member diagnoses capture. Develop and implement tools and metrics to ensure optimal performance. Manage In-home assessment vendor relationship which includes monitoring performance, setting up meetings with representatives, and keeping up to date contract changes. Serve as a liaison to reduce the administrative burden for all new contracts, assist the provider specialist team in monitoring performance and distributing reports to track Key Performance Indicators (KPI). Work cross functionally with Quality, Care Management, and other departments across EmblemHealth to identify opportunities for gap closure, while minimizing costs and provider/member abrasion. Drive Risk Adjustment best-practices across all lines of business. Assist in the gathering of risk adjustment related materials for all regulatory agencies during an audit. Hire, coach, develop, and assess new and existing team members


  • Manage the day to day activities of risk adjustment Vendor functions for Emblem Medicare, Medicaid and ACA members. This will include, but is not limited to, coordinating the risk adjustment data flow from and to vendors, establishing weekly meetings, and building/ tracking current performance reports.
  • Maximize ROI by monitoring and tracking vendor performance against current SLA’s; and by ensuring operational performance of vendor services.  Look for opportunities to in source specific services over time; optimize business performance by coordinating with internal and vendor partners for all related business purposes
  • Track and monitor interventions for all EmblemHealth risk membership
  • Communicate with delegates the overall risk adjustment plan and strategy
  • Manage the day to day implementation, development and management of the Prospective programs and  other initiatives which focuses on ensuring providers are assessing members for suspected chronic conditions; and incorporate identification of members with complex and co-morbid conditions, scheduling visits, developing and redefining provider education regarding coding and documentation, clinical outreach and coordination of interventions to ensure Emblem’s sickest members receive the most appropriate care for their conditions. 
  • Develop a robust set of risk adjustment provider tools and enablement strategies such as coding and documentation education, reporting on key risk adjustment metrics, and integrating the risk adjustment activities with other EmblemHealth business units (i.e., Quality).
  • Utilize analytic platform for tracking provider engagement and distribute data elements as necessary
  • Evaluate performance of large provider groups and shared saving groups, and where underperforming develop an action plan with the provider engagement team
  • Work with Department Director to develop, implement, drive, and monitor activities of the Risk Adjustment Department to optimize revenue.
  • Perform other related duties, tasks, and responsibilities as needed or directed.


  • Bachelor’s degree Required.
  • 10+ years of relevant, professional work experience Required.
  • 5+ years of experience working in Healthcare Required.
  • 2+ years of Population Health Management (specifically Risk Adjustment & or Quality) Required.
  • Additional years of related experience may be considered in lieu of educational requirements Required.
  • Ability to understand/interpret metrics, data and information; and to communicate ideas and concepts effectively. Required.
  • Ability to effectively manage (directly or via matrix relationships) staff, processes, and programs Required.
  • Ability to communicate with all levels of management
  • Excellent communication skills, (verbal, written, interpersonal, presentation) with all types/levels of audiences. Required.

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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