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Position Summary
Revenue Integrity Informaticsis seeking aLead Director, Informaticsto lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and financial valuations. This roleis responsible fordriving risk score accuracy and completeness, ensuring regulatory compliance, and delivering actionable data-informed opportunities. The role is highly visible within the enterprise and will be a key contributor to strategic decision-making with senior management.
The Lead Director will manage a high-performing team with backgrounds in data, analytics, and informatics to build opportunity algorithms, optimize processes, mitigate risks, and create business impact.
This role will work in close partnership with executive leadership, market leaders, finance, service operations, compliance, and vendor partners.
Key Responsibilities
Risk Adjustment & Business Performance
Lead enterprise risk adjustment analytics supporting risk score completeness, accuracy, engagement, recapture, and algorithms.
Leverage claims and clinical data for deep learning into drivers of performance and model impacts.
Proactively engage with stakeholders on emerging trends, rising risk, and data-driven opportunities
Overseethe analytics that drive risk adjustment intervention activities, including prospective and retrospective programs.
Directs the prioritization and performance evaluation of outreach, engagement, and clinical documentation initiatives.
Predictive Analytics, AI & Innovation
Lead the development and implementation of advanced predictive analytics and AI solutions to support risk adjustment, population health, and business performance initiatives.
Drive innovation through automation, advanced analytics, and emerging technologies that improve efficiency and scalability
Measure and evaluate intervention effectiveness and overall business impact
Translate complex analytical findings into practical recommendations that improve operational, clinical, and financial outcomes.
Partner with technology and data engineering teams to enhance data architecture, automation, and analytics capabilities.
Strategic Leadership & Partnerships
Partner with executive leadership, market leaders, finance, actuarial, service operations, and clinical teams to support strategic planning and performance improvement efforts.
Provide executive-level presentations and recommendations that influence organizational strategy and investment decisions.
Manage data relationships with external vendors and business partners
Compliance & Regulatory Support
Ensure adherence to CMS regulations, data governance policies, and organizational compliance expectations.
Lead analytical support for compliance reviews and risk adjustment governance activities
Establish andmaintaincontrols that promote data integrity, auditability, transparency, and accuracy.
Monitor regulatory and industry changes, assess business impact, and ensuretimelyimplementation ofrequiredanalytic and reporting enhancements.
People Leadership
Lead, mentor, and develop a high-performing team of leaders and individual contributors across analytics, informatics, data science, and related disciplines.
Foster a culture of collaboration, innovation, continuous improvement, and results-oriented execution.
Champion technical excellence and continuous learning in areas including risk adjustment analytics, AI modeling, SQL, SAS, Python,BigQuery, and similar
Required Qualifications
10+ years of experience in healthcare analytics, informatics, risk adjustment, actuarial, finance, data science, or related disciplines.
2+ years of leadership experience (direct reports, team lead).
Advanced technicalproficiencyin SQL, SAS, Python,BigQuery, or similar
Experience with predictive analytics, machinelearning, financialmodeling, or data science concepts
Demonstrated ability to influence leadership and deliver measurable business results.
Preferred Qualifications
Demonstrated knowledge of Medicare, Medicaid, or ACA risk adjustment methodologies, HCC models, healthcare claims and clinical data, and CMS regulatory requirements.
Experience at a health plan or provider system
Education:
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, ordemonstratedsubject matterexpertisepreferred
Pay Range
The typical pay range for this role is:
$100,000.00 - $231,540.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.
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