Vp Medicare Jobs in Rio Rancho, NM (NOW HIRING)

Location Address:
9521 San Mateo NEAlbuquerque, NM 87113-2237
Summary:
The Vice President, Health Plan Analytics is the senior leader accountable for advancing analytics and insights across Presbyterian Health Plan. Reporting to the Chief Analytics & Data Officer, this role ensures Health Plan strategy and operations are supported by accurate, timely, and decision-ready analytics that improve affordability, quality, growth, and member experience.
This leader is responsible for regulatory reporting, quality performance analytics, medical cost management, revenue optimization, provider network analytics, and member operations reporting. The VP will modernize and integrate fragmented data environments into a connected and governed platform that supports measurable business value, operational reliability, and value-based care performance.
The ideal candidate brings deep payer experience, has led Health Plan analytics at scale, and understands how to translate complex data into actionable insights that improve financial and operational outcomes. This role also carries significant responsibility for developing talent and building a strong leadership bench within the analytics function.
This position reflects Presbyterian's values of excellence, stewardship, integrity, and compassion and aligns with our analytics commitment to serve with purpose, grow experts, and build what is next.
Work Arrangement:
• Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY.
• Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.
Job Description:
Health Plan Analytics Strategy, Business Value, and Operating Model
• Set and execute the strategic direction for Health Plan analytics in alignment with enterprise priorities for affordability, quality, growth, and member experience.
• Define clear value realization targets for analytics initiatives, linking analytic outputs to measurable financial, regulatory, and operational impact.
• Establish a structured operating model including KPI governance, metric ownership, intake prioritization, and disciplined executive reporting cadences.
• Drive insight generation that informs strategic decisions, performance improvement initiatives, and investment priorities.
• Partner closely with Health Plan executive leadership to ensure analytics are embedded in business planning and operational reviews.
Regulatory, Compliance, and Quality Performance
• Lead all regulatory and compliance analytics including HCA and non-HCA reporting, state and federal submissions, encounter data oversight, and audit readiness.
• Oversee performance analytics for HEDIS, Medicare Stars, CAHPS, HOS, QRS, and accreditation requirements such as NCQA.
• Maintain accurate, timely, and defensible reporting processes supported by strong documentation and internal controls.
• Provide executive oversight for analytics supporting claims, appeals and grievances, call center operations, and member service performance.
• Strengthen governance and quality assurance processes to ensure regulatory compliance and high confidence in reported results.
Medical Cost, Revenue, and Risk Performance
• Oversee claims analytics, total cost of care reporting, revenue management support, and collaboration on risk adjustment performance.
• Lead unit cost analysis, medical trend monitoring, PCP attribution redesign, and provider directory data integrity.
• Support encounter submission accuracy, payment integrity programs, and financial forecasting.
• Provide actionable insights to optimize performance across utilization management, pharmacy management, and network economics.
• Partner with Sales and Marketing to support product performance analytics, enrollment, retention, and billing accuracy.
Provider Network, Value-Based Care, and Population Health
• Support provider network strategy and contracting through transparent and actionable cost and quality reporting.
• Enable value-based care arrangements with reliable performance measurement and shared-risk monitoring.
• Advance population health analytics including risk stratification, segmentation, care gap identification, and equity reporting.
• Integrate claims, clinical, pharmacy, and social determinants data to support performance improvement and care management initiatives.
Population Health Analytics
• Lead and integrate population health analytics as a core capability within Health Plan performance, advancing risk stratification, segmentation, care gap identification, and equity insights to improve quality, cost, and outcomes across member populations.
• Drive alignment between payer and provider perspectives by connecting claims, clinical, pharmacy, and social determinants data to enable value-based care, care management effectiveness, and proactive intervention strategies.
• Ensure population health insights are embedded into operational workflows, program design, and performance management, with clear linkage to total cost of care, quality improvement, and health equity outcomes.
Data Modernization, Technology Partnership, and Master Data Discipline
• Partner closely with Information Technology leadership to align analytic strategy with enterprise data architecture and platform modernization efforts.
• Lead the integration of Health Plan data assets into a scalable, governed analytics environment that supports both operational and strategic needs.
• Establish strong master data management practices across provider, member, product, and contract domains to ensure consistency and integrity.
• Define and enforce data quality standards, validation processes, and metric governance to ensure high-quality analytics.
• Develop curated data sets, standardized definitions, and reusable analytic assets that improve consistency and reduce redundancy.
• Promote responsible use of advanced analytics and automation to improve forecasting, operational efficiency, and insight generation.
Leadership, Coaching, and Talent Development
• Build and lead a high-performing Health Plan analytics organization with clear accountability and performance expectations.
• Develop Directors and senior managers through active coaching, structured development plans, and succession planning.
• Establish competency models and career pathways that strengthen analytic, technical, and business capabilities.
• Cultivate future enterprise analytics leaders and expand analytic literacy across Health Plan leadership.
• Foster a culture of ownership, collaboration, continuous improvement, and high standards for analytic rigor.
Additional Job Description:
Education
Bachelor's degree required in business administration, health administration, public health, data science, actuarial science, health informatics, or a related field.
Advanced degree or relevant actuarial, clinical, or quality credential preferred.
Experience
• 15 or more years of progressive leadership experience in Health Plan analytics within a payer or integrated payer-provider organization.
• Experience leading regulatory reporting including HCA and non-HCA submissions, encounter reporting, and compliance-driven analytics.
• Demonstrated leadership of HEDIS, Medicare Stars, CAHPS, HOS, QRS, and accreditation-aligned performance programs.
• Proven oversight of claims analytics, total cost of care reporting, revenue performance, and provider analytics.
• Experience supporting provider network strategy, PCP attribution redesign, and value-based contracting models.
• Operational partnership experience across utilization management, pharmacy, enrollment, billing, call center operations, and appeals and grievances.
• Experience partnering with IT and data engineering teams to modernize analytic platforms and strengthen data governance.
• Track record of building and developing high-performing analytics teams.
Skills and Competencies
• Deep knowledge of payer regulatory frameworks, compliance analytics, and quality measurement.
• Strong understanding of claims data, risk adjustment methodologies, and Health Plan financial drivers.
• Ability to connect analytics to measurable business outcomes.
• Strong partnership orientation with IT, Finance, Operations, and Clinical leadership.
• Expertise in data governance, master data management, and data quality assurance.
• Ability to translate complex data into clear, actionable insights for executive and operational leaders.
• Commitment to integrity, stewardship, and continuous improvement.
• Demonstrated success developing talent and strengthening organizational capability.
Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
• Continuing education and career development opportunities
• Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.