Lead Director, Healthcare Medicaid Risk Adjustment Analytics

Position Summary

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.

Key Responsibilities

• 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

• 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
• Define data analysis methodologies, subsequently driving predictive and prescriptive analytics projects and communicating insights to key stakeholders

• 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

• 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

• 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 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.)

Preferred Qualifications

• 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