Virginia Premier Health Plan, Inc.

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Director, Risk Programs

Director, Risk Programs

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Job Description


The Director of Risk Programs is responsible for implementing and managing new and existing Medicare and Medicaid programs. The position is responsible for supporting, and driving revenue enhancement as well as monitoring financial performance and providing analytic support for all products offered. This position will be responsible for revenue management, risk sharing development, risk analysis, financial statement analysis, participation in the benefit design, and Medicare and Medicaid reports and reconciliations. This position will be responsible for supporting risk adjustment development and implementation for Medicare and Medicaid. This position will also be responsible for implementing HCC and CDPS risk adjustment models for Medicare and Medicaid, respectively.


  • Oversee analytic support for Medicare and Medicaid programs
  • Demonstrate expert knowledge of the CMS-HCC risk adjustment methodologies including Medicare Advantage and Medicare Part D.
  • Demonstrate expert knowledge of the Chronic illness and Disability Payment System (CDPS) risk adjustment methodologies
  • Manage the Hierarchical Condition Category (HCC) revenue function to ensure accuracy of risk scores at the member level.
  • Provide Subject Matter Expertise (SME) to support program managers to implement HCC and CDPS risk adjustment models
  • Support development and implementation of retrospective and prospective assessments for risk revenue optimization
  • Manage relationship with retrospective and prospective assessments vendors
  • Support development of annual budget and medical expenses in detail.
  • Drive process with Plan leadership in coordination with senior management.
  • Monitor financial performance and provide analytic support for all products offered.
  • Explain the financial impacts of various reimbursement issues.
  • Support audits, appeals, and provide analytical support for CMS risk adjustment data validation audits.
  • Initiate and help manage miscellaneous projects relative to reimbursement and other net revenue initiatives.
  • Monitor Medicare and Medicaid legislative and regulatory changes.
  • Assume other responsibilities as directed.



  • Bachelor’s degree.
  • Preferred: Master’s degree.
  • Medicare or Medicaid Related Background with 3 + years of risk adjustment experience with Managed Care Organization.
  • Basic Microsoft Project, Visio, Adobe Acrobat; intermediate Microsoft Word, PowerPoint, advanced Microsoft Excel, Access skills are required.
  • Managed a team of financial, healthcare or business analysts for at least 1-3 years.
  • Experience leading cross functional business teams.
  • Strong analytic skills.
  • Ability to work with large data sets.


  • Five years of healthcare finance/medical economics experience.
  • Deep understanding of Medicaid or Medicare risk score methodologies.
  • Deep understanding of various reimbursement methodologies (all patient refined diagnosis related groups and Medicare severity diagnosis related groups)
  • Capability to negotiate rates and terms. *


  • Physical health sufficient to meet the ergonomic standards and demands of the position.

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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