Quality Improvement Specialist , Risk Adjustment, Covered California

Quality Improvement Specialist , Risk Adjustment, Covered California

• 494246
• 505 City Parkway West, California, United States
• Administrative
• Full Time
• Closing at: Nov 8 2026 - 23:55 PST

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Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Quality Improvement Specialist , Risk Adjustment, Covered California and help shape the future of healthcare where you'll be an integral part of our Quality Analytics team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Quality Improvement Specialist (Risk Adjustment) will be responsible for documentation and monitoring to ensure the accuracy, completeness and compliance of Affordable Care Act (ACA) Commercial, Medicare Advantage and Medicaid risk adjustment data. You''ll review documentation, Hierarchical Condition Category (HCC) validation and provide audit support. Additionally, you''ll support program integrity. Additionally, you''ll support CalOptima Health's risk adjustment programs, including monitoring, tracking, reporting, medical record retrieval, retrospective and prospective coding and provider engagement. Finally, you''ll also adhere to official regulatory guidelines and the industry's best practices. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 85% - Measurable Performance Functions

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

• Works with multiple business units in the implementation of action items/requirements related to Quality Improvement for risk adjustment.

• Supports with Health and Human Services (HHS)-RADV audit documentation requirements, timelines, progress and initial validation auditor pass and failure rates.

• Collaborates with Provider Relations to coordinate health network engagement for risk adjustment program initiatives, risk adjustment data validation (RADV) audit communications and webinars and provides annual wellness visit distribution and reports outcomes.

• Assists with completing root cause and impact analyses to determine the success of initiatives, projects and pilots to quality measure performance.

• Develops run charts, control charts and other graphical representations of Continuous Quality Improvement (CQI) project metrics as appropriate.

• Develops a tracker to monitor HCC capture rate, trending and accuracy.

• Tracks reporting on provider documentation improvement trends.

• Distributes monthly HCC analytic reporting to support provider outreach efforts.

• Coordinates to help facilitate health network meetings related to risk adjustment.

• Monitors provider engagement success rate by programs.

• Supports edge implementation by tracking External Data Gathering Environment (EDGE) file acceptance rates.

• Provides regular and frequent feedback to management on the status of CalOptima Health's risk adjustment program and outcomes.

• Supports with provider engagement and outreach for annual wellness visits and other quality initiatives.

• Assists in tracking program budget costs and return on investment (ROIs).

• Supports member engagement initiatives to align with improved health outcomes.

• 10% - Risk Adjustment Program Support

• Ensures the coordination of processes, protocols and data flow between risk adjustment and cross-functional teams, resulting in appropriate follow-up deliverables and quality improvement activities.

• Supports with provider communications and follow-ups for chart retrieval projects.

• Tracks provider feedback and annual wellness visit insights.

• Coordinates and maintains vendor project meetings.

• Monitors adherence to member contact protocol for appropriate member engagement for the annual wellness visits and in-home assessment programs.

• 5% - Other

• Completes other duties and projects as assigned.

Do You Have What the Role Requires?

• Bachelor's degree in health care, health care data informatics or a related field PLUS 2 years of risk adjustment or quality improvement working experience in a health plan or medical group required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

• Have access to means of transportation for work away from the primary office approximately 10% of the time required.

You'll Stand Out More If You Possess the Following:

• Experience with HHS-RADV demographic and enrollment data validation mapping documentation.

• Experience with encounter data validation study, medical record documentation and submission.

• Experience with risk adjustment programs for Medicare, Covered California and Medicaid.

What the Regulatory Agencies Need You to Possess?

• N/A

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health''s leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You'll enjoy competitive compensation for this role.

• Our current hiring range is: Pay Grade: 309 - $68,015 - $108,824 ($32.70 - $52.3192).

• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

• This position is approved for Partial Telework (If the position is Telework, it is eligible in California only)

• A comprehensive benefits package

• CalPERS pension program and additional retirement packages.

• Additional benefits and perks including:

• A generous PTO program

• A quality work life balance

• Various wellness programs

• Tuition Reimbursement

• Professional development opportunities

• Career development opportunities

• Flexible scheduling

• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone''s input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What''s Your Next Step?

All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is October 21, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Our Commitment to You

Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.

We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.