Lead Director, Healthcare Medicaid Risk Adjustment Analytics

Job not on LinkedIn

🕒 August 6

🏈 Alabama, Arizona, +43 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🏛️ District of Columbia – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $100k - $231.5k / year

⏰ Full Time

🟠 Senior

👨‍⚕️ Medical Director

👻 Ghost score 10%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Define and execute Medicaid risk adjustment strategy across markets and plans • Lead strategic initiatives improving revenue accuracy, compliance, and performance • Align risk adjustment programs with state Medicaid models such as CDPS, CRG, and state-specific methodologies • Represent Medicaid informatics in executive forums and translate analytics into financial and operational strategies • Oversee health plan performance analytics and reporting • Lead scalable data pipelines and reporting frameworks using claims, encounters, pharmacy, and clinical data • Lead predictive modeling, forecasting, trend analysis, and opportunity identification • Ensure accuracy, integrity, and completeness of Medicaid encounter submissions • Reconcile plan-calculated risk scores with state-reported scores and identify root causes of variances • Monitor encounter submissions and their impact on state risk scoring and payments • Partner with actuarial and finance teams on risk scores, revenue projections, and state payments • Ensure readiness for state audits and external reviews • Direct suspecting logic, gap identification, prioritization, and program performance evaluation • Establish program KPIs and partner with clinical operations and vendors • Lead and develop a multidisciplinary informatics, analytics, reporting, and program-support team • Establish governance, organizational structures, and standardized tools and processes • Drive automation and data infrastructure improvements

🎯 Requirements

• 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 such as BigQuery, Snowflake, or Databricks • Expertise in state and regulatory requirements, risk adjustment methodologies, and encounter data processes • Strong knowledge of risk models such as CDPS, CRG, and HCC and state reconciliation processes • Proven ability to develop and execute strategic initiatives delivering measurable business outcomes • Demonstrated leadership experience managing cross-functional teams and large-scale programs • Experience with data visualization tools such as Tableau, Power BI, QuickSight, or Looker • Knowledge of Medicaid Risk Adjustment • Experience working with Medicaid Risk models • Experience within a large national health plan or payer organization • Master’s degree in Health Informatics, Data Science, Actuarial, Statistics, or MBA preferred • Bachelor's degree preferred, specialized training, or relevant professional qualification

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • Award target in the company’s equity award program • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being