Lead Director, Medicare Advantage, Group ACA Risk Adjustment Informatics

Job not on LinkedIn

🕒 July 24

🏈 Alabama, Arizona, +42 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – 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

🎲 Risk

👻 Ghost score 27%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and financial valuations • Drive risk score accuracy and completeness while ensuring regulatory compliance • Manage a high-performing team of approximately 5 direct reports and overall scope of 13 • Build opportunity algorithms, optimize processes, mitigate risks, and create business impact • Partner with executive leadership, market leaders, finance, service operations, compliance, clinical teams, technology, data engineering, and vendor partners • Lead analytics supporting risk score completeness, accuracy, engagement, recapture, and algorithms • Leverage claims and clinical data to analyze performance drivers and model impacts • Oversee analytics for prospective and retrospective risk adjustment intervention programs • Prioritize and evaluate outreach, engagement, and clinical documentation initiatives • Develop and implement predictive analytics and AI solutions • Drive automation, advanced analytics, and emerging technology innovation • Measure intervention effectiveness and business impact • Translate analytical findings into operational, clinical, and financial recommendations • Enhance data architecture, automation, and analytics capabilities • Provide executive-level presentations and recommendations influencing strategy and investment decisions • Manage data relationships with external vendors and business partners • Ensure adherence to CMS regulations, data governance policies, and compliance expectations • Lead analytical support for compliance reviews and risk adjustment governance • Establish and maintain controls for data integrity, auditability, transparency, and accuracy • Monitor regulatory and industry changes and implement required analytical and reporting enhancements • Lead, mentor, and develop analytics, informatics, data science, and related teams • Champion technical excellence and continuous learning in risk adjustment analytics, AI modeling, SQL, SAS, Python, and BigQuery

🎯 Requirements

• 10+ years of experience in healthcare analytics, informatics, risk adjustment, actuarial, finance, data science, or related disciplines • 2+ years of leadership experience, including direct reports or team lead experience • Advanced technical proficiency in SQL, SAS, Python, BigQuery, or similar • Experience with predictive analytics, machine learning, financial modeling, or data science concepts • Demonstrated ability to influence leadership and deliver measurable business results • Knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements preferred • Experience at a health plan or provider system preferred • Bachelor’s degree or equivalent professional work experience • Master’s degree in Business, Informatics, Analytics, Finance, Statistics, Computer Science, Public Health, Healthcare Analytics, Actuarial, Mathematics, Economics, or equivalent combination of advanced education, professional certification, or demonstrated subject matter expertise preferred

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program • Equity award program