Program Integrity Director Jobs in Simsbury, CT (NOW HIRING)

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Position Summary
Revenue Integrity Informatics is seeking a Lead Director - Revenue Integrity Informatics (Medicaid) to join our highly dynamic Risk Adjustment analytics team. This senior-level role will provide strategic and operational leadership for all Medicaid risk adjustment analytics, reporting, and informatics functions to ensure complete, accurate, and compliant revenue capture.

This leader oversees the end-to-end risk adjustment lifecycle, including data management, suspecting, analytic insights, risk score reconciliation, and performance monitoring. They partner closely with clinical, actuarial, finance, market plans, and compliance stakeholders to support health plan and enterprise initiatives while ensuring alignment with state Medicaid and CMS regulatory requirements.

The Lead Director should also demonstrate leadership in innovation and adoption of modern technologies, data platforms, machine learning, process automation, AI, and data science for optimized insights, workflows, reporting, and process controls. This role will lead a team of managers and individual contributors with backgrounds in data science, analytics, statistics, data engineering, and informatics.

Key Responsibilities

1. Strategic Leadership

• 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 to drive alignment on strategic goals and translate analytics into actionable financial and operational strategies

2. Performance Analytics & Reporting

• 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

• Lead advanced analytics for risk score development, predictive modeling, forecasting, trend analysis, and opportunity identification

• Ensure accuracy, integrity and completeness of Medicaid encounter submissions and data

• Defines data analysis methodologies, subsequently driving predictive and prescriptive analytics projects and communicating insights to key stakeholders.

3. Risk Score Integrity & Reconciliation

• Establish and oversee processes to ensure accuracy, completeness, and integrity of risk capture

• Lead reconciliation of plan-calculated risk scores to state-reported scores, including variance analysis and root cause identification

• Monitor and validate encounter data submissions and their downstream impact on state risk scoring and payments

• Partner with actuarial and finance teams to ensure alignment between risk scores, revenue projections, and state payments

• Ensure readiness for state audits and external reviews through robust data validation and documentation practices

• Stay current on evolving Medicaid policies, state methodologies, and reporting requirements

4. Risk Adjustment Operational & Program Insights

• Direct suspecting logic development, gap identification, and prioritization strategies for operational programs and interventions

• Measure and evaluate program performance and locate opportunities for expansion, improvement, or savings

• Establish program KPIs to monitor intervention effectiveness

• Partner with clinical operations and vendor teams to ensure alignment with state requirements

• Align data strategies with value-based initiatives and provider-level drilldowns for consistent performance management across markets

5. Team Leadership & Talent Development

• Lead and develop a high-performing, multidisciplinary team spanning informatics, risk analytics, reporting, and operational program support

• Define a clear organizational structure, aligning roles across strategy, analytics, and process execution to ensure end-to-end accountability

• Establish governance frameworks for prioritization and execution of risk adjustment initiatives, ensuring alignment with enterprise goals, market needs, and regulatory timelines

• Drive integration across analytics and operations, ensuring that insights are translated into actionable intervention programs and measurable outcomes

• Develop talent strategy including coaching and mentorship of advanced analytics, Medicaid risk models, and leadership capabilities

• Foster a culture of data integrity, accountability, and continuous improvement optimization of workflows and analytic methodologies

• Ensure scalability and sustainability of operations by standardizing tools, reporting, and processes across markets

• Leverage automation and data infrastructure improvements to reduce manual effort and increase speed to insight

Required Qualifications

• 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.).

Preferred Qualifications

• Knowledge of Medicaid Risk Adjustment

• Working with Medicaid Risk models

• Master's degree (e.g., Health Informatics, Data Science, Actuarial, Statistics, or MBA) preferred

• Experience working within a large national health plan or payer organization

Education

Bachelor's degree preferred/specialized training/relevant professional qualification.

Pay Range

The typical pay range for this role is:

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.