Lead Director Medical Policy Optimization and Customization

CVS Health•Work At Home-Connecticut, CT

1d•$100,000 - $231,540•Remote

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. Lead Director, MPPS Compliance & Policy Optimization, provides strategic leadership for enterprise policy compliance and optimization functions, ensuring regulatory adherence, effective governance, quality excellence, and continuous improvement while minimizing risk and enabling business objectives through collaborative stakeholder engagement and data-driven decision-making. This role is not operational and does not include vendor oversight.

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 people leadership experience managing professional staff & cross-functional teams
Demonstrated experience leading enterprise-wide policy programs and governance frameworks
Experience presenting to executive leadership and governance committees
Strategic thinker with the ability to align policy governance with organizational goals and business strategy
Proven ability to influence without authority across matrixed organizations
Strong executive presence and communication skills
Demonstrated 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, (i.e. CPC, RHIT, CCS, or equivalent healthcare/coding credential) or must obtain credential/certification within one year of employment

Responsibilities

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