Lead Director, Medical Policy Optimization and Customization

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🔥 0 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $100k - $231.5k / year

⏰ Full Time

🟠 Senior

👨‍⚕️ Medical Director

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Provide strategic leadership for enterprise policy compliance and optimization functions • Lead enterprise oversight of policy adherence to regulatory, contractual, and organizational requirements • Establish and maintain governance frameworks across all lines of business • Monitor regulatory and industry changes, assess business impact, and direct required policy updates • Ensure policies align with applicable federal, state, and internal standards • Direct policy deviation activities arising from audits, assessments, regulatory findings, and business decisions • Develop and execute strategies to enhance policy management processes and reduce compliance risk • Drive continuous improvement across policy development, review, approval, and quality oversight • Identify opportunities to simplify policy structures while maintaining compliance and business objectives • Establish metrics and performance indicators to evaluate policy effectiveness • Ensure effective controls support compliance and business integrity • Partner with business, legal, compliance, clinical, operational, and technology stakeholders • Facilitate executive-level decisions on policy interpretation, implementation, and risk mitigation • Lead cross-functional teams for policy initiatives, regulatory readiness, deviation management, and process improvement • Develop executive-level reporting and dashboards on policy performance, effectiveness, risks, and opportunities • Analyze trends, audit findings, and operational data to inform strategic decisions • Present recommendations and outcomes to senior leadership and governance committees

🎯 Requirements

• 10+ years of progressive leadership experience in policy governance, compliance, healthcare operations, payment integrity, medical policy, utilization management, risk management, or related functions • 7+ years of people leadership experience managing professional staff and cross-functional teams • Experience leading enterprise-wide policy programs and governance frameworks • Experience presenting to executive leadership and governance committees • Ability to align policy governance with organizational goals and business strategy • Ability to influence without authority across matrixed organizations • Strong executive presence and communication skills • Ability to lead organizational change and drive adoption of new processes • Bachelor’s degree in healthcare administration, business, public health, or related field, or equivalent experience • Relevant certification and/or current license required, such as CPC, RHIT, CCS, or equivalent healthcare/coding credential, or must obtain credential/certification within one year of employment

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Award target in the company’s equity award program • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being