Executive Director, Medicare Appeals

CVS Health • Hartford, CT

9d • Hybrid

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Role Overview At Aetna, our health benefits business, we are committed to helping our members achieve their best health in an affordable, convenient, and comprehensive manner. Combining the assets of our health insurance products and services with CVS Health’s unrivaled presence in local communities and their pharmacy benefits management capabilities, we’re joining members on their path to better health and transforming the health care landscape in new and exciting ways every day. The Executive Director, Medicare Appeals serves as the Aetna leader accountable for the effective management of Medicare Advantage Member and Non‑Participating (Non‑Par) Provider appeals operations. This role ensures that Medicare Advantage member and non-participating provider appeals are processed accurately, timely, and in full compliance with CMS regulations, while driving operational consistency, audit readiness, Stars performance, and strong member and provider experience outcomes. The Executive Director leads multi‑level clinical and administrative teams and partners closely with the Appeals Intake Center of Excellence, Medicare Par Provider Appeals, Medicare Grievance/CTM, Claims, G&A Insights and Root Cause, Medical Affairs, Medical Policy, Utilization Management, Finance, IT, and other enterprise stakeholders to deliver compliant, high‑quality appeals outcomes and continuous improvement across the Medicare organization.

Requirements

• 10+ years’ experience in health plan operations management.
• Demonstrated success leading large, complex operations with direct management of people leaders.
• Strong knowledge of Medicare Advantage (Part A/B) benefits, coverage rules, and appeals‑related CMS regulations will be highly valued.
• Demonstrated ability to manage performance, productivity, and budgets in large operational environments.
• Strong understanding of operating large processes on a technology backbone, including workforce management and workflow optimization.
• Proven ability to partner across clinical, operational and enterprise teams.
• Demonstrated ability to operate effectively in highly matrixed organizations.
• Strong executive presence with the ability to influence, align, and drive decisions across senior stakeholders.
• Analytical and process‑oriented mindset, with experience using data to drive operational performance and continuous improvement.
• Bachelor’s degree or equivalent.
• Ability to work Hybrid Model in a CVS Health Office.

Nice To Haves

• Clinical degree will be valued.

Responsibilities

• Provide strategic and operational leadership for Medicare Member Appeals, Non‑Participating Provider Appeals, and QIO Fast Track Appeals.
• Ensure full compliance with CMS regulations, federal and state requirements, and accreditation standards governing Medicare appeals.
• Establish and maintain quality processes that support data integrity, documentation accuracy, and regulatory defensibility.
• Lead preparation for and response to CMS audits, internal audits, and other regulatory reviews, in close partnership with Compliance and Internal Audit.
• Drive performance against production, quality, and timeliness standards that directly impact CMS Stars measures.
• Partner closely with Medical Affairs, Medical Policy, and Utilization Management on appeal decisioning and clinical alignment.
• Lead cross‑functional efforts to identify root cause drivers of appeals and implement actions to reduce avoidable appeal volume.
• Oversee development and use of operational reporting for daily, weekly, and monthly performance monitoring.
• Oversee large‑scale appeals operations supported by workforce management, workflow technology, and reporting platforms.
• Partner with IT to optimize appeals systems, improve scalability, and enhance productivity and decision‑making.
• Apply a continuous improvement mindset across processes, staffing models, and technology‑enabled workflows.
• Serve as the Medicare Appeals subject matter expert across the organization, clearly communicating trends, risks, and performance to senior leaders.
• Oversee P&L for Medicare Member, Non‑Par Provider, and Fast Track Appeals functions.
• Foster a culture of accountability, ownership, and disciplined execution across a large, front‑line operational environment.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive
• Number of Employees: 5,001-10,000 employees