Lead Director Revenue Integrity - ACA

Job DescriptionReporting to the Executive Director of ACA Revenue Integrity, the Lead Consultant, ACA Revenue Integrity will work closely with cross-functional leadership across the ACA Individual (IVL) business to establish and champion local market culture committed to revenue integrity excellence. In collaboration with the Executive Director and Revenue Integrity Centers of Excellence, this position is responsible for reviewing all activities (programs, analysis, data submission and quality assurance) across the ACA IVL revenue integrity processes related to risk adjustment (RA) focused on complete and accurate diagnosis capture and reporting within a heavily matrixed organization. Through partnership with local market teams and appropriate governance processes, this position will ensure initiatives are optimized across functions and are consistent among health plans.Collaborating with the Executive Director of Revenue Integrity, the Lead Consultant will, focus on,Strategy & Execution:- Identify and develop market level risk adjustment strategies to strengthen ACA-IVL risk score performance.- Execute upon local market strategies to drive correctness, completeness, accuracy, and timeliness of risk score performance.- Jointly identify VBCs/non-VBCs to prioritize with risk score performance initiatives including developing strategy on members, VBC providers, and providers that get embedded coder training.- Develops processes, workflows, and other materials to document the operational and strategic components of initiative.Data Analysis & Reporting: - Work closely with the Informatics team to review requirements, dashboards, reports including any enhancements.- Conduct data analyses using national tools in conjunction with the corporate lead to identify areas of opportunity.- Produce and present dashboards specific to ACA-IVL Revenue Integrity efforts at various governance, market, and executive leadership meetings.Market Support: - Establish and champion local market culture committed to revenue integrity and excellence.- Act as a face of Revenue Integrity across internal market teams and external providers.- Support local market colleagues in ensuring strategic and optimal product and pricing discussions, including attending and hosting trainings.Performance Management: - Partners with the Corporate Revenue Integrity program leads to monitor and drive high quality outcomes.- Manage and direct local vendors when appropriate. - Engage with clinical team and specific clinics, medical groups, hospitals; attends JOC meetings; Supports engagement managers and RN program novation:- Partner with segment product, sales, network, clinical teams to implement processes aimed at strengthening member and provider engagement of Revenue Integrity programs resulting in improved outcomes.- Actively participate in key projects impacting commercial Revenue Integrity efforts.Required Qualifications- Bachelor's Degree from an accredited college/university required.- 10-15 years of overall healthcare experience including 5-7 years of ACA risk adjustment experience and 5-8 years of experience in Business Development or Client Management Leadership.- Knowledge of insurance regulatory and contractual requirements.- Demonstrated ability to identify, develop and execute strategy.- Strong affinity in understanding large audience needs and ability to deal effectively with a diverse workforce and cross functional groups- Strong facilitative leadership and business problem solving skills.- Knowledge of value-based provider contract/agreements.- Other tasks and projects as directed by supervisor or manager.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Master's degree or management development program preferred.- Deep knowledge of local markets across the enterprise.- Experience working in a highly matrixed environment.- Previous experience working for a large national carrierEducation- Bachelor's Degree from an accredited college/university requiredBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15