Lead Director, Healthcare Medicaid Risk Adjustment Analytics

CVS Health•Washington, NV

7d•$100,000 - $231,540

About The Position

Revenue 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.

Requirements

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 teams and large-scale programs
Experience with data visualization tools (e.g. Tableau, Power BI, QuickSight, Looker, etc.).

Nice To Haves

Knowledge of Medicaid Risk Adjustment
Working with Medicaid Risk models
Master’s degree (e.g., Health Informatics, Data Science, Actuarial, Statistics, or MBA) preferred
Experience working within a large national health plan or payer organization

Responsibilities

Define and execute Medicaid risk adjustment strategy across markets and plans
Lead and deliver high-impact strategic initiatives that improve revenue accuracy, compliance, and overall performance
Align 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 strategies
Oversee health plan performance using advanced analytics and use proactive data insights to drive strategies and evidence-based decision-making
Lead development of scalable data pipelines and reporting frameworks using claims, encounters, pharmacy, and clinical data
Lead advanced analytics for risk score development, predictive modeling, forecasting, trend analysis, and opportunity identification
Ensure accuracy, integrity and completeness of Medicaid encounter submissions and data
Defines data analysis methodologies, subsequently driving predictive and prescriptive analytics projects and communicating insights to key stakeholders.
Establish and oversee processes to ensure accuracy, completeness, and integrity of risk capture
Lead reconciliation of plan-calculated risk scores to state-reported scores, including variance analysis and root cause identification
Monitor and validate encounter data submissions and their downstream impact on state risk scoring and payments
Partner with actuarial and finance teams to ensure alignment between risk scores, revenue projections, and state payments
Ensure readiness for state audits and external reviews through robust data validation and documentation practices
Stay current on evolving Medicaid policies, state methodologies, and reporting requirements
Direct suspecting logic development, gap identification, and prioritization strategies for operational programs and interventions
Measure and evaluate program performance and locate opportunities for expansion, improvement, or savings
Establish program KPIs to monitor intervention effectiveness
Partner with clinical operations and vendor teams to ensure alignment with state requirements
Align data strategies with value-based initiatives and provider-level drilldowns for consistent performance management across markets
Lead and develop a high-performing, multidisciplinary team spanning informatics, risk analytics, reporting, and operational program support
Define a clear organizational structure, aligning roles across strategy, analytics, and process execution to ensure end-to-end accountability
Establish governance frameworks for prioritization and execution of risk adjustment initiatives, ensuring alignment with enterprise goals, market needs, and regulatory timelines
Drive integration across analytics and operations, ensuring that insights are translated into actionable intervention programs and measurable outcomes
Develop talent strategy including coaching and mentorship of advanced analytics, Medicaid risk models, and leadership capabilities
Foster a culture of data integrity, accountability, and continuous improvement optimization of workflows and analytic methodologies
Ensure scalability and sustainability of operations by standardizing tools, reporting, and processes across markets
Leverage automation and data infrastructure improvements to reduce manual effort and increase speed to insight