Director, Strategic Analytics - Prospective Risk Adjustment

Director, Strategic Analytics - Prospective Risk Adjustment

This position is flexible and the individual may reside in any KP authorized state including California, Oregon, Colorado, Washington, Hawaii, Georgia, Maryland and Washington DC. The Prospective Risk Adjustment Operations team is seeking a highly analytical and technically proficient Director to lead advanced data science initiatives that drive strategic performance in prospective risk adjustment. This leadership role is accountable for designing and executing complex analytic strategies-including benchmarking, prevalence tracking, cohort stratification, predictive modeling, and suspecting logic-to optimize risk capture and support clinical and operational decision-making. The Director will bring deep domain expertise in CMS-HCC and HHS-HCC & RXC frameworks, with a strong understanding of chronic vs. acute coding implications, recapture logic, and disease prevalence trends. A critical focus will be on developing scalable analytic solutions that inform member targeting, provider engagement, and program compliance, while translating complex data into actionable insights.

This role demands fluency in SQL, SAS, or Python to drive data extraction, validation, and advanced analytics, as well as a strong grasp of healthcare claims data-including ICD, CPT / HCPCS, bill type, and revenue codes-and familiarity with risk adjustment submission systems such as EDPS and EDGE. The ideal candidate will be proficient in statistical modeling, regression analysis, variance normalization across markets, and ACA payment transfer modeling. Expertise in hypothesis testing and significance interpretation is essential to support critical thinking and insight generation.

The Director will be responsible for synthesizing complex findings into clear, compelling narratives that support strategic decision-making and stakeholder alignment. Experience in government-sponsored health programs such as Medicare Advantage or ACA is strongly preferred.

Essential Responsibilities :

• Demonstrates continuous learning and maintains a highly skilled and engaged workforce by aligning resource plans with business objectives; overseeing the recruitment, selection, and development of talent; motivating teams; preparing individuals for growth opportunities and advancement; staying current with industry trends, benchmarks, and best practices; providing guidance when difficult decisions need to be made; and ensuring performance management guidelines and expectations drive business needs.
• Oversees the operation of multiple units and / or departments by identifying customer and operational needs; analyzing resources, costs, and forecasts and incorporating them into business plans; gaining cross-functional support for business plans and priorities; translating business strategy into actionable business requirements; obtaining and distributing resources; setting standards and measuring progress; removing obstacles that impact performance; guiding performance and developing contingency plans accordingly; and ensuring products and / or services meet customer requirements and expectations while aligning with organizational strategies.
• Oversees data and information collection on targeted variables in an established systematic fashion by establishing data collection, refresh, and update standards; approving data collection sources; reviewing and approving data sources; directing the development and / or delivery of tools for electronic data collection; ensuring users are trained and supported; and auditing documentation.
• Directs data preparation for analytic efforts by establishing data quality and accuracy standards; approving system improvements to enhance overall quality of data; championing the resolution of critical issues as appropriate; and reviewing complex or high-profile data sets.
• Oversees the execution of creative data analytic approaches leading to actionable outcomes across one or more functional areas, business and / or clinical lines by reviewing and approving strategic data design and analysis; and establishing data analysis strategy that aligns with and advances organizational needs.
• Oversees the development, implementation, and automation of business and reporting strategies by partnering with key stakeholders to ensure their design, planning, and implementation needs are being met while ensuring alignment with strategic business objectives; reviewing and approving results and roadmaps as appropriate; ensuring compliance with standards and guidelines for data reports, visualizations, and / or interactive Business Intelligence (BI) reports; and sharing insights with stakeholders on key findings.
• Oversees data analysis interpretation by establishing analysis interpretation strategy; providing support to team on complex data interpretation; approving high-profile findings and their application to contextual settings; and reviewing insights, reports, and presentations to ensure a compelling story to stakeholders to enable and influence decision making; and sharing insights with internal and / or external audiences.
• Directs and influences strategic data-informed decision making by overseeing team(s) of professionals in the consultation of clients to identify and clarify key business needs across functional areas, business and / or clinical lines; translating business strategy; establishing data analytics strategy; approving complex data collection methods and analysis plans; reviewing the impact of business decisions on clients, customers, and / or members; building and leveraging partnerships with clients and staff to identify opportunities and methods to improve efficiencies with analysis; ensuring end-users are supported and trained; and establishing guidelines for proper documentation of processes and deliverables.

Minimum Qualifications :

Additional Requirements :

Preferred Qualifications :