Lead Director - Performance Analytics & Optimization

CVS Health•Colorado Springs, IN

2d•$100,000 - $231,540

About The Position

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. This Lead Director will provide objective oversight of edit performance, savings realization, edit accuracy, quality, false-positive rates, production quality, and continuous optimization across the Payment Integrity editing portfolio, including GCP, Lyric, Cotiviti, and related editing solutions.

Requirements

5+ years of progressive experience in healthcare, Payment Integrity, claims, analytics, data, operations, or a related field.
5+ years of leadership experience managing teams and/or complex enterprise programs.
Demonstrated experience leading analytics-driven performance management.
Experience working with large, complex datasets and translating data into business decisions.
Experience developing executive dashboards and performance reporting.

Nice To Haves

Experience with healthcare claims data and payment integrity strongly preferred.
Experience with claims editing, prepay/post-pay processes, or claims platforms strongly preferred.
Demonstrated experience with continuous improvement and optimization methodologies.

Responsibilities

Establish and maintain a standardized performance measurement framework across all Payment Integrity editing platforms.
Monitor edit performance following deployment and throughout the edit lifecycle.
Develop and maintain KPIs and performance scorecards for the editing portfolio.
Analyze trends in claims, savings, utilization, provider behavior, and edit outcomes.
Identify underperforming, overperforming, or anomalous edits requiring investigation.
Establish performance thresholds and triggers for optimization or remediation.
Provide executive-level reporting and insights to Payment Integrity leadership.
Own the independent measurement and validation of edit savings.
Monitor expected versus realized savings following deployment.
Identify variance between projected and actual financial performance.
Partner with Finance and Payment Integrity leadership to establish consistent savings methodologies.
Ensure savings reporting is accurate, transparent, repeatable, and supported by data.
Identify opportunities to improve savings realization through optimization.
Establish an independent quality assurance framework for deployed edits.
Monitor edit accuracy and effectiveness across GCP, Lyric, Cotiviti, and other editing solutions.
Evaluate whether edits are producing the intended outcome after deployment.
Identify quality defects, unintended outcomes, and opportunities for remediation.
Establish quality standards, sampling methodologies, and ongoing monitoring practices.
Provide objective feedback to editing and solution design teams.
Establish enterprise standards for measuring edit precision, recall, and false-positive rates.
Monitor edits for inappropriate or unnecessary claim impacts.
Identify edits with high false-positive rates or unfavorable provider/member impact.
Partner with editing teams to determine appropriate optimization strategies.
Balance financial opportunity with edit accuracy, provider experience, and operational efficiency.
Establish a structured continuous optimization process for the editing portfolio.
Identify opportunities to modify, refine, expand, reduce, or retire edits based on performance data.
Develop optimization recommendations based on empirical performance rather than anecdotal feedback.
Establish post-deployment review cycles and performance thresholds.
Ensure optimization activities are prioritized based on financial impact, quality, risk, and operational value.
Track optimization recommendations through completion and measure resulting impact.
Establish a centralized performance reporting strategy for Payment Integrity editing.
Oversee development and maintenance of Power BI dashboards and executive reporting.