Lead Director, Healthcare Medicaid Risk Adjustment Analytics

About this role

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
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

2. Performance Analytics & Reporting
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.

3. Risk Score Integrity & Reconciliation
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

4. Risk Adjustment Operational & Program Insights
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

5. Team Leadership & Talent Development
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

Required 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…