Executive Director, Revenue Integrity Analytics and Performance Optimization

CVS Health•Hartford, CT

About The Position

The Executive Director, Revenue Integrity Analytics & Performance Optimization leads the Aetna strategy, investment planning, governance, and execution of risk adjustment analytics, performance reporting, forecasting, provider performance analytics, and encounter data submissions across Medicare Advantage, Medicaid, and ACA. This role serves as the owner for translating complex member, provider, and encounter-level data into actionable financial, operational, and investment insight, enabling senior leadership to prioritize initiatives, allocate resources, and optimize returns across risk adjustment programs. The Executive Director ensures performance transparency, accurate forecasting, and regulatory readiness while driving adoption of advanced analytics and AI-enabled solutions in close partnership with Revenue Integrity, Provider Performance, Actuarial, Finance, Encounter Data Operations, Compliance, Technology, and Market Leadership.

Requirements

10–15+ years of experience in healthcare analytics, risk adjustment, actuarial analytics, or performance strategy within a health plan or payer-adjacent organization.
Demonstrated experience supporting Medicare Advantage, Medicaid, and/or ACA risk adjustment analytics.
Senior people leadership experience, managing leaders and influencing at the executive level.
Proven experience with provider-level performance analytics and encounter data.
Ability to deliver executive-level reporting and translate analytics into strategic and financial insight.
Strong executive presence with the ability to influence across a highly matrixed, enterprise organization.
Bachelor’s degree in Analytics, Finance, Economics, Mathematics, Public Health, or a related field or equivalent experience.

Nice To Haves

Experience supporting RADV, EDGE, or CMS encounter data reviews.
Advanced proficiency in SQL, Python, SAS, Tableau, and/or Power BI.
Experience operating in large, complex enterprises.
Familiarity with Revenue Integrity, Provider Performance, and actuarial partnership models.
Master’s degree in Business, Analytics, Public Health, or a related discipline.

Responsibilities

Lead Aetna’s risk adjustment analytics, including risk score development, trend analysis, performance attribution, and opportunity identification across Medicare Advantage, Medicaid, and ACA.
Own analytics-led Revenue Integrity investment strategy, providing data-driven recommendations on where to deploy capital, technology, and operational resources to maximize performance and financial returns.
Deliver proactive insights to executive and senior leadership on emerging risks, forecast variance, provider trends, and documentation effectiveness, including ROI and prioritization implications.
Establish standardized analytical frameworks to assess drivers of performance across members, providers, programs, and markets.
Provide forward-looking insight on financial risk and opportunity related to CMS model updates, policy changes, and operational trends.
Partner with Finance and Actuarial to support bids, budgets, accruals, and multi-year planning using analytically grounded assumptions.
Champion advanced analytics, automation, predictive modeling, and AI-enabled solutions to improve risk identification, forecasting, and performance optimization.
Partner with Technology, Data Engineering, and Data Science to modernize analytics pipelines, reporting infrastructure, and enterprise insight delivery.
Incorporate external benchmarks and industry best practices to continuously evolve analytics maturity at scale.
Provide ownership of provider risk adjustment performance analytics at the provider, group, network, and regional levels.
Develop standardized performance scorecards and dashboards assessing: Risk score contribution and persistence, Diagnosis capture, coding completeness, and documentation quality, Gap closure effectiveness and intervention outcomes, Performance variation by market, specialty, and geography.
Partner within Revenue Integrity, Provider Performance, and clinical teams to translate insights into targeted, ROI-driven interventions.
Quantify provider-driven impacts to enterprise risk scores, revenue, and long-term performance sustainability.
Provide analytical governance over Medicare Advantage EDS and ACA EDGE submissions.
Partner with Encounter Data Operations, IT/Data Engineering, Compliance, and Risk Adjustment Operations to ensure completeness, accuracy, acceptance rates, and timeliness.
Link documentation and coding behavior to encounter outcomes and downstream risk adjustment performance.
Quantify and report financial exposure and reconciliation impacts tied to encounter data gaps or quality issues.
Oversee enterprise dashboards integrating risk adjustment, provider performance, encounter health, and financial impact into a unified executive performance view.
Ensure reconciled, consistent reporting of risk scores, KPIs, encounter metrics, and financial outcomes.
Translate complex analytics into concise, board- and executive-ready insights supporting decision-making, prioritization, and investment allocation.
Partner with Actuarial and Finance on forecasting, accruals, budget-to-actual analysis, and reconciliation readiness.
Incorporate Medicare payment adjustments, including MSP and ESRD considerations, into enterprise modeling and reporting.
Ensure analytics and reporting align with CMS requirements for Medicare Advantage and ACA.
Support RADV, EDGE, and related audits through defensible analytics, root cause analysis, and transparent executive reporting.
Proactively identify compliance and financial risks tied to documentation, encounter submissions, and performance trends.
Establish analytics governance standards ensuring consistency, transparency, and executive confidence across markets and programs.
Lead and develop high-performing analytics leaders and subject matter experts.
Build scalable analytics capabilities through automation and advanced analytical methods.
Foster a culture of rigor, accountability, innovation, and continuous improvement.
Develop succession-ready talent and scalable leadership capacity across analytics functions.