Lead Director, Healthcare Medicaid Risk Adjustment Analytics

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position SummaryRevenue Integrity Informatics is seeking a Lead Director - Revenue Integrity Informatics (Medicaid) to join our highly dynamic Risk Adjustment analytics team. This senior-level role will provide strategic and operational leadership for all Medicaid risk adjustment analytics, reporting, and informatics functions to ensure complete, accurate, and compliant revenue capture.This leader oversees the end-to-end risk adjustment lifecycle, including data management, suspecting, analytic insights, risk score reconciliation, and performance monitoring. They partner closely with clinical, actuarial, finance, market plans, and compliance stakeholders to support health plan and enterprise initiatives while ensuring alignment with state Medicaid and CMS regulatory requirements.The Lead Director should also demonstrate leadership in innovation and adoption of modern technologies, data platforms, machine learning, process automation, AI, and data science for optimized insights, workflows, reporting, and process controls. This role will lead a team of managers and individual contributors with backgrounds in data science, analytics, statistics, data engineering, and informatics.Key Responsibilities 1. Strategic LeadershipDefine and execute Medicaid risk adjustment strategy across markets and plansLead and deliver high-impact strategic initiatives that improve revenue accuracy, compliance, and overall performanceAlign risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state-specific methodologies)Represent risk adjustment Medicaid informatics in executive forums to drive alignment on strategic goals and translate analytics into actionable financial and operational strategies2. Performance Analytics & ReportingOversee health plan performance using advanced analytics and use proactive data insights to drive strategies and evidence-based decision-makingLead development of scalable data pipelines and reporting frameworks using claims, encounters, pharmacy, and clinical dataLead advanced analytics for risk score development, predictive modeling, forecasting, trend analysis, and opportunity identificationEnsure accuracy, integrity and completeness of Medicaid encounter submissions and dataDefines data analysis methodologies, subsequently driving predictive and prescriptive analytics projects and communicating insights to key stakeholders.3. Risk Score Integrity & ReconciliationEstablish and oversee processes to ensure accuracy, completeness, and integrity of risk captureLead reconciliation of plan-calculated risk scores to state-reported scores, including variance analysis and root cause identificationMonitor and validate encounter data submissions and their downstream impact on state risk scoring and paymentsPartner with actuarial and finance teams to ensure alignment between risk scores, revenue projections, and state paymentsEnsure readiness for state audits and external reviews through robust data validation and documentation practicesStay current on evolving Medicaid policies, state methodologies, and reporting requirements4. Risk Adjustment Operational & Program InsightsDirect suspecting logic development, gap identification, and prioritization strategies for operational programs and interventionsMeasure and evaluate program performance and locate opportunities for expansion, improvement, or savingsEstablish program KPIs to monitor intervention effectivenessPartner with clinical operations and vendor teams to ensure alignment with state requirementsAlign data strategies with value-based initiatives and provider-level drilldowns for consistent performance management across markets5. Team Leadership & Talent DevelopmentLead and develop a high-performing, multidisciplinary team spanning informatics, risk analytics, reporting, and operational program supportDefine a clear organizational structure, aligning roles across strategy, analytics, and process execution to ensure end-to-end accountabilityEstablish governance frameworks for prioritization and execution of risk adjustment initiatives, ensuring alignment with enterprise goals, market needs, and regulatory timelinesDrive integration across analytics and operations, ensuring that insights are translated into actionable intervention programs and measurable outcomesDevelop talent strategy including coaching and mentorship of advanced analytics, Medicaid risk models, and leadership capabilitiesFoster a culture of data integrity, accountability, and continuous improvement optimization of workflows and analytic methodologiesEnsure scalability and sustainability of operations by standardizing tools, reporting, and processes across marketsLeverage automation and data infrastructure improvements to reduce manual effort and increase speed to insightRequired Qualifications • 10+ years of experience in healthcare analytics and reporting, risk adjustment including relevant working knowledge with claims • 3+ years of leadership experience including people managing, coaching, or mentoring team members • Advanced technical skills in SAS, SQL, Python, or cloud-based analytics platforms (e.g. BigQuery, Snowflake, Databricks, or similar) • Expertise in state and regulatory requirements, risk adjustment methodologies, and encounter data processes • Strong knowledge of risk models (e.g., CDPS, CRG, HCC) and state reconciliation processes • Proven ability to develop and execute strategic initiatives that deliver measurable business outcomes • Demonstrated leadership experience managing cross-functional tea