Executive Leader, Medicaid Risk Adjustment Analytics

Hispanic Alliance for Career Enhancement; Massachusetts; Hybrid; USD 100,000 - 231,540; Full time

Benefits offered by this job

Comprehensive benefits

Bonus eligibility

Equity award program

Job summary

CVS Health is seeking a Lead Director for Revenue Integrity Informatics (Medicaid) to lead a dynamic analytics team responsible for Medicaid risk adjustment, reporting, and informatics. You will drive strategic initiatives, ensure data integrity, and align risk scores with state payments across markets.

The role requires extensive healthcare analytics leadership, expertise in CDPS/CRG/HCC, and advanced data skills.

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).
• Expertise in state and regulatory requirements, risk adjustment methodologies, and encounter data processes.
• Strong knowledge of risk models (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 (Tableau, Power BI, QuickSight, Looker, etc.).

Responsibilities

• Define and execute Medicaid risk adjustment strategy across markets and plans.
• Oversee health plan performance using advanced analytics and data pipelines.
• Lead reconciliation of plan-calculated risk scores to state-reported scores and audits.
• Direct suspecting logic development and KPIs to monitor program performance.
• Lead and develop a multidisciplinary team spanning informatics, risk analytics, and operations.

Job description

CVS Health is seeking a Lead Director for Revenue Integrity Informatics (Medicaid) to lead a dynamic analytics team responsible for Medicaid risk adjustment, reporting, and informatics. You will drive strategic initiatives, ensure data integrity, and align risk scores with state payments across markets.

The role requires extensive healthcare analytics leadership, expertise in CDPS/CRG/HCC, and advanced data skills.