Lead Director, Healthcare Medicaid Risk Adjustment Analytics

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.

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.

• 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 drill downs 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…