Lead Director, Risk Adjustment Informatics

Role Description

Revenue Integrity Informatics is seeking a Lead Director, Informatics to lead Medicare Advantage and ACA risk adjustment analytics, predictive modeling, intervention strategy, and financial valuations. This role is responsible for driving 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.
  • Oversee the analytics that drive risk adjustment intervention activities, including prospective and retrospective programs.
  • Direct 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 and maintain controls that promote data integrity, auditability, transparency, and accuracy.
  • Monitor regulatory and industry changes, assess business impact, and ensure timely implementation of required analytic 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.

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 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.

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, or demonstrated subject matter expertise preferred.

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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.