MPPS Policy Customization Lead Director

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🔥 1 minute ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $100k - $231.5k / year

⏰ Full Time

🟠 Senior

👔 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

• Direct medical, clinical, and payment policy SAI processes • Lead teams executing projects from initiation through completion • Collaborate with clinical, coding, operations, compliance, technology, Medical Economics, product lines, and Network stakeholders • Secure resources and manage resources, budgets, risks, and changes • Assess roadblocks and ensure timely, on-specification, and within-budget completion • Develop strategic plans for projects and programs to improve policy performance, claim accuracy, and regulatory compliance • Prepare and present SAI progress reports to stakeholders and senior management • Administer continuous improvement across the SAI lifecycle • Direct research, authoring, evaluation, and implementation of medical, clinical, and payment policies • Ensure policies use evidence-based practices and comply with federal and state regulations • Establish business requirements and coding architecture for accurate configuration and operational success • Use data-driven insights to inform strategic decisions and improvements • Direct operational review teams on policy interpretation • Mentor a high-performing team of policy clinical and coding subject-matter leaders, project managers, and/or project coordinators • Direct a portfolio of complex, cross-functional MPPS projects through intake, planning, execution, monitoring, and closure • Ensure projects meet scope, business objectives, and regulatory objectives • Direct standardized Agile, Waterfall, and hybrid project management methodologies • Implement continuous improvement initiatives and maintain tools, templates, and SOPs • Facilitate governance forums, decision-making bodies, and cross-functional working sessions • Communicate program status, risks, and key decisions to senior leadership and stakeholders • Establish and track KPIs for project and program success • Lead policy experts supporting regulatory investigations, state fair hearings, and CMS audits • Implement issue resolution and escalation strategies • Ensure audit readiness and compliance with internal controls and regulatory requirements • Deliver executive-level reporting on SAI progress, outcomes, and operational impact

🎯 Requirements

• 10+ years of experience in project or program management • 10+ years of healthcare experience in a health plan, payer, or related environment • Emphasis on medical policy, payment integrity, and improvement of cost of care • Strong understanding of Medicare and Medicaid regulations • Expertise leading cross-functional initiatives affecting operations, policy, or compliance • Advanced project/program management expertise across large-scale, cross-functional initiatives • Mastery of problem-solving, prioritizing, and decision-making in a fast-paced environment • Mastery of a growth mindset approach, including agility in developing self and others • Experience in medical policy, payment policy, claims operations, or utilization management preferred • Experience with Lean Six Sigma, process improvement, Agile, and hybrid delivery models preferred • Experience supporting regulatory or audit-driven initiatives such as CMS and HIPAA preferred • Experience with SAI system implementations, configuration, or policy deployment initiatives preferred • Bachelor’s degree in business administration, healthcare administration, public health, or related field required, or equivalent experience • Medical coding certification such as CPC, CCS, CPMA, or RHIT required, or must obtain within 1 year of employment • Clinical licensure such as RN, LPN, or PA preferred

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • 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, based on eligibility