Lead Director, Healthcare Medicaid Risk Adjustment Analytics

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🔥 1 minute ago

🦌 Connecticut, Idaho, +1 more states – Remote

🦌 Connecticut – Remote 🥔 Idaho – Remote 🤠 Texas – Remote

💵 $100k - $231.5k / year

⏰ Full Time

🟠 Senior

👨‍⚕️ Medical Director

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

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 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 • 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 • Ensure accuracy, integrity and completeness of Medicaid encounter submissions and data • Establish and oversee processes to ensure accuracy, completeness, and integrity of risk capture • Direct suspecting logic development, gap identification, and prioritization strategies for operational programs and interventions • Lead and develop a high-performing, multidisciplinary team spanning informatics, risk analytics, reporting, and operational program support

🎯 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 (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.).

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs