Executive Director, Revenue Integrity Analytics and Performance Optimization
U.S. Bankruptcy Court - District of CT, Hartford, CT, United States
At CVS Health® you will be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do.
Executive Director, Revenue Integrity Analytics & Performance Optimization
This role leads the Aetna strategy, investment planning, governance, and execution of risk adjustment analytics, performance reporting, forecasting, provider performance analytics, and encounter data submissions across Medicare Advantage, Medicaid, and ACA.
The Executive Director translates complex member, provider, and encounter-level data into actionable financial, operational, and investment insight, enabling senior leadership to prioritize initiatives, allocate resources, and optimize returns across risk adjustment programs. The role ensures performance transparency, accurate forecasting, regulatory readiness and drives adoption of advanced analytics and AI‑enabled solutions in partnership with Revenue Integrity, Provider Performance, Actuarial, Finance, Encounter Data Operations, Compliance, Technology and Market Leadership.
Key Responsibilities
Enterprise Risk Adjustment Analytics, Strategy & Investment Planning
Lead Aetna's risk adjustment analytics, including risk score development, trend analysis, performance attribution, and opportunity identification across Medicare Advantage, Medicaid, and ACA.
Own analytics‑led Revenue Integrity investment strategy, providing data‑driven recommendations on where to deploy capital, technology, and operational resources to maximize performance and financial returns.
Deliver proactive insights to executive and senior leadership on emerging risks, forecast variance, provider trends, and documentation effectiveness, including ROI and prioritization implications.
Establish standardized analytical frameworks to assess drivers of performance across members, providers, programs, and markets.
Provide forward‑looking insight on financial risk and opportunity related to CMS model updates, policy changes, and operational trends.
Partner with Finance and Actuarial to support bids, budgets, accruals, and multi‑year planning using analytically grounded assumptions.
Champion advanced analytics, automation, predictive modelling, and AI‑enabled solutions to improve risk identification, forecasting, and performance optimisation.
Partner with Technology, Data Engineering, and Data Science to modernise analytics pipelines, reporting infrastructure, and enterprise insight delivery.
Incorporate external benchmarks and industry best practices to continuously evolve analytics maturity at scale.
Provider Risk Adjustment Performance Analytics
Provide ownership of provider risk adjustment performance analytics at the provider, group, network, and regional levels.
Develop standardised performance scorecards and dashboards assessing risk score contribution and persistence, diagnosis capture, coding completeness, documentation quality, gap closure effectiveness, intervention outcomes, and performance variation by market, specialty, and geography.
Partner within Revenue Integrity, Provider Performance, and clinical teams to translate insights into targeted, ROI‑driven interventions.
Quantify provider‑driven impacts to enterprise risk scores, revenue, and long‑term performance sustainability.
Encounter Data Submission Oversight (Medicare & ACA)
Provide analytical governance over Medicare Advantage EDS and ACA EDGE submissions.
Partner with Encounter Data Operations, IT/Data Engineering, Compliance, and Risk Adjustment Operations to ensure completeness, accuracy, acceptance rates, and timeliness.
Link documentation and coding behaviour to encounter outcomes and downstream risk adjustment performance.
Quantify and report financial exposure and reconciliation impacts tied to encounter data gaps or quality issues.
Executive Reporting, Forecasting & Performance Management
Oversee enterprise dashboards integrating risk adjustment, provider performance, encounter health, and financial impact into a unified executive performance view.
Ensure reconciled, consistent reporting of risk scores, KPIs, encounter metrics, and financial outcomes.
Translate complex analytics into concise, board‑ and executive‑ready insights supporting decision‑making, prioritisation, and investment allocation.
Partner with Actuarial and Finance on forecasting, accruals, budget‑to‑actual analysis, and reconciliation readiness.
Incorporate Medicare payment adjustments, including MSP and ESRD considerations, into enterprise modelling and reporting.
Regulatory, Compliance & Enterprise Governance
Ensure analytics and reporting align with CMS requirements for Medicare Advantage and ACA.
Support RADV, EDGE, and related audits through defensible analytics, root cause analysis, and transparent executive reporting.
Proactively identify compliance and financial risks tied to documentation, encounter submissions, and performance trends.
Establish analytics governance standards ensuring consistency, transparency, and executive confidence across markets and programmes.
People Leadership & Capability Development
Lead and develop high‑performing analytics leaders and subject‑matter experts.
Build scalable analytics capabilities through automation and advanced analytical methods.
Foster a culture of rigor, accountability, innovation, and continuous improvement.
Develop succession‑ready talent and scalable leadership capacity across analytics functions.
Qualifications
Required
10-15+ years of experience in healthcare analytics, risk adjustment, actuarial analytics, or performance strategy within a health plan or payer‑adjacent organisation.
Demonstrated experience supporting Medicare Advantage, Medicaid, and/or ACA risk adjustment analytics.
Senior people‑leadership experience, managing leaders and influencing at the executive level.
Proven experience with provider‑level performance analytics and encounter data.
Ability to deliver executive‑level reporting and translate analytics into strategic and financial insight.
Strong executive presence with the ability to influence across a highly matrixed, enterprise organisation.
Bachelor's degree in Analytics, Finance, Economics, Mathematics, Public Health, or a related field or equivalent experience.
Preferred
Experience supporting RADV, EDGE, or CMS encounter data reviews.
Advanced proficiency in SQL, Python, SAS, Tableau, and/or Power BI.
Experience operating in large, complex enterprises.
Familiarity with Revenue Integrity, Provider Performance, and actuarial partnership models.
Master's degree in Business, Analytics, Public Health, or a related discipline.
Pay Range
The typical pay range for this role is:
$131,500.00 – $303,195.00
This 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 factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive programme in addition to the base pay range listed above. It also includes an award target in the company's equity award programme.
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. The full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Benefits include medical, dental and vision coverage, paid time off, retirement savings options, wellness programmes, and other resources, based on eligibility.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
#J-18808-Ljbffr
Executive Director, Revenue Integrity Analytics & Performance Optimization
This role leads the Aetna strategy, investment planning, governance, and execution of risk adjustment analytics, performance reporting, forecasting, provider performance analytics, and encounter data submissions across Medicare Advantage, Medicaid, and ACA.
The Executive Director translates complex member, provider, and encounter-level data into actionable financial, operational, and investment insight, enabling senior leadership to prioritize initiatives, allocate resources, and optimize returns across risk adjustment programs. The role ensures performance transparency, accurate forecasting, regulatory readiness and drives adoption of advanced analytics and AI‑enabled solutions in partnership with Revenue Integrity, Provider Performance, Actuarial, Finance, Encounter Data Operations, Compliance, Technology and Market Leadership.
Key Responsibilities
Enterprise Risk Adjustment Analytics, Strategy & Investment Planning
Lead Aetna's risk adjustment analytics, including risk score development, trend analysis, performance attribution, and opportunity identification across Medicare Advantage, Medicaid, and ACA.
Own analytics‑led Revenue Integrity investment strategy, providing data‑driven recommendations on where to deploy capital, technology, and operational resources to maximize performance and financial returns.
Deliver proactive insights to executive and senior leadership on emerging risks, forecast variance, provider trends, and documentation effectiveness, including ROI and prioritization implications.
Establish standardized analytical frameworks to assess drivers of performance across members, providers, programs, and markets.
Provide forward‑looking insight on financial risk and opportunity related to CMS model updates, policy changes, and operational trends.
Partner with Finance and Actuarial to support bids, budgets, accruals, and multi‑year planning using analytically grounded assumptions.
Champion advanced analytics, automation, predictive modelling, and AI‑enabled solutions to improve risk identification, forecasting, and performance optimisation.
Partner with Technology, Data Engineering, and Data Science to modernise analytics pipelines, reporting infrastructure, and enterprise insight delivery.
Incorporate external benchmarks and industry best practices to continuously evolve analytics maturity at scale.
Provider Risk Adjustment Performance Analytics
Provide ownership of provider risk adjustment performance analytics at the provider, group, network, and regional levels.
Develop standardised performance scorecards and dashboards assessing risk score contribution and persistence, diagnosis capture, coding completeness, documentation quality, gap closure effectiveness, intervention outcomes, and performance variation by market, specialty, and geography.
Partner within Revenue Integrity, Provider Performance, and clinical teams to translate insights into targeted, ROI‑driven interventions.
Quantify provider‑driven impacts to enterprise risk scores, revenue, and long‑term performance sustainability.
Encounter Data Submission Oversight (Medicare & ACA)
Provide analytical governance over Medicare Advantage EDS and ACA EDGE submissions.
Partner with Encounter Data Operations, IT/Data Engineering, Compliance, and Risk Adjustment Operations to ensure completeness, accuracy, acceptance rates, and timeliness.
Link documentation and coding behaviour to encounter outcomes and downstream risk adjustment performance.
Quantify and report financial exposure and reconciliation impacts tied to encounter data gaps or quality issues.
Executive Reporting, Forecasting & Performance Management
Oversee enterprise dashboards integrating risk adjustment, provider performance, encounter health, and financial impact into a unified executive performance view.
Ensure reconciled, consistent reporting of risk scores, KPIs, encounter metrics, and financial outcomes.
Translate complex analytics into concise, board‑ and executive‑ready insights supporting decision‑making, prioritisation, and investment allocation.
Partner with Actuarial and Finance on forecasting, accruals, budget‑to‑actual analysis, and reconciliation readiness.
Incorporate Medicare payment adjustments, including MSP and ESRD considerations, into enterprise modelling and reporting.
Regulatory, Compliance & Enterprise Governance
Ensure analytics and reporting align with CMS requirements for Medicare Advantage and ACA.
Support RADV, EDGE, and related audits through defensible analytics, root cause analysis, and transparent executive reporting.
Proactively identify compliance and financial risks tied to documentation, encounter submissions, and performance trends.
Establish analytics governance standards ensuring consistency, transparency, and executive confidence across markets and programmes.
People Leadership & Capability Development
Lead and develop high‑performing analytics leaders and subject‑matter experts.
Build scalable analytics capabilities through automation and advanced analytical methods.
Foster a culture of rigor, accountability, innovation, and continuous improvement.
Develop succession‑ready talent and scalable leadership capacity across analytics functions.
Qualifications
Required
10-15+ years of experience in healthcare analytics, risk adjustment, actuarial analytics, or performance strategy within a health plan or payer‑adjacent organisation.
Demonstrated experience supporting Medicare Advantage, Medicaid, and/or ACA risk adjustment analytics.
Senior people‑leadership experience, managing leaders and influencing at the executive level.
Proven experience with provider‑level performance analytics and encounter data.
Ability to deliver executive‑level reporting and translate analytics into strategic and financial insight.
Strong executive presence with the ability to influence across a highly matrixed, enterprise organisation.
Bachelor's degree in Analytics, Finance, Economics, Mathematics, Public Health, or a related field or equivalent experience.
Preferred
Experience supporting RADV, EDGE, or CMS encounter data reviews.
Advanced proficiency in SQL, Python, SAS, Tableau, and/or Power BI.
Experience operating in large, complex enterprises.
Familiarity with Revenue Integrity, Provider Performance, and actuarial partnership models.
Master's degree in Business, Analytics, Public Health, or a related discipline.
Pay Range
The typical pay range for this role is:
$131,500.00 – $303,195.00
This 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 factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive programme in addition to the base pay range listed above. It also includes an award target in the company's equity award programme.
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. The full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Benefits include medical, dental and vision coverage, paid time off, retirement savings options, wellness programmes, and other resources, based on eligibility.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
#J-18808-Ljbffr