Lead Director, Healthcare Medicaid Risk Adjustment Analytics
Job Title: Lead Director, Healthcare Medicaid Risk Adjustment Analytics
Job Location: Work at Home, Connecticut, United States
Job Location Type: Remote
Job Contract Type: Full time
Job Seniority Level:
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 Summary
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.
Key Responsibilities
1. Strategic Leadership
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Define and execute Medicaid risk adjustment strategy across markets and plans
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Lead and deliver high-impact strategic initiatives that improve revenue accuracy, compliance, and overall performance
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Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state-specific methodologies)
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Represent risk adjustment Medicaid informatics in executive forums to drive alignment on strategic goals and translate analytics into actionable financial and operational strategies
2. Performance Analytics & Reporting
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Oversee health plan performance using advanced analytics and use proactive data insights to drive strategies and evidence-based decision-making
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Lead development of scalable data pipelines and reporting frameworks using claims, encounters, pharmacy, and clinical data
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Lead advanced analytics for risk score development, predictive modeling, forecasting, trend analysis, and opportunity identification
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Ensure accuracy, integrity and completeness of Medicaid encounter submissions and data
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Defines data analysis methodologies, subsequently driving predictive and prescriptive analytics projects and communicating insights to key stakeholders.
3. Risk Score Integrity & Reconciliation
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Establish and oversee processes to ensure accuracy, completeness, and integrity of risk capture
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Lead reconciliation of plan-calculated risk scores to state-reported scores, including variance analysis and root cause identification
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Monitor and validate encounter data submissions and their downstream impact on state risk scoring and payments
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Partner with actuarial and finance teams to ensure alignment between risk scores, revenue projections, and state payments
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Ensure readiness for state audits and external reviews through robust data validation and documentation practices
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Stay current on evolving Medicaid policies, state methodologies, and reporting requirements
4. Risk Adjustment Operational & Program Insights
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Direct suspecting logic development, gap identification, and prioritization strategies for operation